Provider Demographics
NPI:1013324367
Name:BRYANT, LANE MARIE (PA-C)
Entity type:Individual
Prefix:
First Name:LANE
Middle Name:MARIE
Last Name:BRYANT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:LANE
Other - Middle Name:MARIE
Other - Last Name:ERICKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:203 S ROLLIE AVE
Mailing Address - Street 2:BILLING DEPT - CREDENTIALIST
Mailing Address - City:FORT LUPTON
Mailing Address - State:CO
Mailing Address - Zip Code:80621-1508
Mailing Address - Country:US
Mailing Address - Phone:303-286-4560
Mailing Address - Fax:303-286-4589
Practice Address - Street 1:1860 E EGBERT ST
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:CO
Practice Address - Zip Code:80601-2475
Practice Address - Country:US
Practice Address - Phone:303-659-4000
Practice Address - Fax:303-659-9306
Is Sole Proprietor?:No
Enumeration Date:2014-07-18
Last Update Date:2016-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0003983363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO96781386Medicaid
CO96781386Medicaid