Provider Demographics
NPI:1669415188
Name:LANE, MICHAEL J (PA-C)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:J
Last Name:LANE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1603
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83701-1603
Mailing Address - Country:US
Mailing Address - Phone:208-424-9101
Mailing Address - Fax:208-424-5072
Practice Address - Street 1:388 E. PARKCENTER BLVD.
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706
Practice Address - Country:US
Practice Address - Phone:208-424-9101
Practice Address - Fax:208-424-5072
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2014-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA377363A00000X
IDM7247207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806272300Medicaid
ID806272301Medicaid
ID000010140814OtherBLUE SHIELD OF ID; BOISE
IDDI593OtherBLUE CROSS OF ID
ID000010145063OtherBLUE SHIELD OF ID; EMMETT
ID000010145063OtherBLUE SHIELD OF ID; EMMETT