Provider Demographics
NPI:1689686578
Name:LANE, BRIAN E (PA-C)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:E
Last Name:LANE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1802 N CARSON ST STE 100
Mailing Address - Street 2:
Mailing Address - City:CARSON CITY
Mailing Address - State:NV
Mailing Address - Zip Code:89701-1227
Mailing Address - Country:US
Mailing Address - Phone:775-888-6610
Mailing Address - Fax:775-887-7047
Practice Address - Street 1:47 W OWENS AVE
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89030-6865
Practice Address - Country:US
Practice Address - Phone:702-307-4635
Practice Address - Fax:702-307-4631
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2012-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPA575363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1689686578Medicaid
NV31957Medicare ID - Type Unspecified
NV1689686578Medicaid
NVEP339ZMedicare PIN