Provider Demographics
NPI:1801105077
Name:LANE, EDWARD KENDRICK (PA-C)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:KENDRICK
Last Name:LANE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4900 S MONACO ST
Mailing Address - Street 2:#210
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80237-3486
Mailing Address - Country:US
Mailing Address - Phone:303-394-9355
Mailing Address - Fax:303-388-8564
Practice Address - Street 1:4500 E 9TH AVE STE 450
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80220-3933
Practice Address - Country:US
Practice Address - Phone:303-394-9355
Practice Address - Fax:303-388-8564
Is Sole Proprietor?:No
Enumeration Date:2010-10-05
Last Update Date:2022-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO3034363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO35257229Medicaid
COCOA103335Medicare PIN
CO35257229Medicaid