Provider Demographics
NPI:1295561470
Name:LASANE, WILBUR JR (CPT)
Entity type:Individual
Prefix:MR
First Name:WILBUR
Middle Name:
Last Name:LASANE
Suffix:JR
Gender:M
Credentials:CPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1931 GIANT PINE AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89031-5071
Mailing Address - Country:US
Mailing Address - Phone:725-200-0821
Mailing Address - Fax:
Practice Address - Street 1:1931 GIANT PINE AVE
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89031-5071
Practice Address - Country:US
Practice Address - Phone:725-200-0821
Practice Address - Fax:702-710-9972
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-12
Last Update Date:2024-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV1241242665171400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171400000XOther Service ProvidersHealth & Wellness Coach