Provider Demographics
NPI:1821102203
Name:LANE, KEVIN A SR (PA-C)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:A
Last Name:LANE
Suffix:SR
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 1:622 W 168TH ST # VC-260
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10032-3720
Mailing Address - Country:US
Mailing Address - Phone:212-305-6059
Mailing Address - Fax:347-479-1303
Practice Address - Street 1:622 W 168TH ST # VC-260
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-3720
Practice Address - Country:US
Practice Address - Phone:212-305-6059
Practice Address - Fax:347-479-1303
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA002999363A00000X
MDC0003531363A00000X
NY005639363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY5F1061Medicare ID - Type Unspecified
MD159838ZED6Medicare PIN
MDS583Medicare PIN
2021970817Medicare PIN
MDP00830451OtherR/R MEDICARE PIN
NYP53327Medicare UPIN
MDCA8374OtherR/R MEDICARE GROUP PIN