Provider Demographics
NPI:1689337784
Name:LANE, MIKENZIE (PA-C)
Entity Type:Individual
Prefix:
First Name:MIKENZIE
Middle Name:
Last Name:LANE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MIKENZIE
Other - Middle Name:
Other - Last Name:LANE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:3503 SAMSON WAY STE 108
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:NE
Mailing Address - Zip Code:68123-4303
Mailing Address - Country:US
Mailing Address - Phone:402-592-2055
Mailing Address - Fax:402-592-2419
Practice Address - Street 1:3503 SAMSON WAY STE 108
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:NE
Practice Address - Zip Code:68123-4303
Practice Address - Country:US
Practice Address - Phone:402-592-2055
Practice Address - Fax:402-592-2419
Is Sole Proprietor?:No
Enumeration Date:2021-10-16
Last Update Date:2023-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant