Provider Demographics
NPI:1295792992
Name:LANE, LISA GABRIEL (PA)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:GABRIEL
Last Name:LANE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:300 MARKET STREET, STE 112
Mailing Address - Street 2:
Mailing Address - City:CHAPEL HILL
Mailing Address - State:NC
Mailing Address - Zip Code:27516
Mailing Address - Country:US
Mailing Address - Phone:919-969-9611
Mailing Address - Fax:919-969-9611
Practice Address - Street 1:300 MARKET STREET, STE 112
Practice Address - Street 2:
Practice Address - City:CHAPEL HILL
Practice Address - State:NC
Practice Address - Zip Code:27516
Practice Address - Country:US
Practice Address - Phone:919-969-9611
Practice Address - Fax:919-969-9615
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2018-08-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA515363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
57183OtherFALLON COMMUNITY HEALTH
AP0278OtherMEDICARE B
042472266OtherTRICARE CHAMPUS
4142200OtherMVP HEALTH CARE
44944OtherHEALTHY START
8300399OtherEVERCARE
042472266OtherTHREE RIVERS
44944OtherCHILDRENS MED SECURITY