Provider Demographics
NPI:1962023820
Name:LANE, PAUL RYAN (PA-C)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:RYAN
Last Name:LANE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4101 N WATER TOWER PL
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864-6296
Mailing Address - Country:US
Mailing Address - Phone:618-244-6222
Mailing Address - Fax:618-246-1247
Practice Address - Street 1:4101 N WATER TOWER PL
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-6296
Practice Address - Country:US
Practice Address - Phone:618-244-6222
Practice Address - Fax:618-246-1247
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-01
Last Update Date:2020-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.007905363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty