Provider Demographics
NPI:1992849244
Name:GARY, KENNETH LANE (NP)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:LANE
Last Name:GARY
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4521 OAK RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:SULPHUR
Mailing Address - State:LA
Mailing Address - Zip Code:70665-9379
Mailing Address - Country:US
Mailing Address - Phone:337-526-2777
Mailing Address - Fax:
Practice Address - Street 1:701 CYPRESS ST
Practice Address - Street 2:
Practice Address - City:SULPHUR
Practice Address - State:LA
Practice Address - Zip Code:70663-5053
Practice Address - Country:US
Practice Address - Phone:337-527-4270
Practice Address - Fax:337-527-4288
Is Sole Proprietor?:No
Enumeration Date:2007-02-19
Last Update Date:2015-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN094922-AP04928363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1019631Medicaid
LA3A582Medicare PIN