Provider Demographics
NPI:1811998644
Name:PETRI, LANE LOUISE (A/GNP)
Entity type:Individual
Prefix:MS
First Name:LANE
Middle Name:LOUISE
Last Name:PETRI
Suffix:
Gender:F
Credentials:A/GNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1921 W HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85704-7806
Mailing Address - Country:US
Mailing Address - Phone:520-544-5210
Mailing Address - Fax:520-544-5355
Practice Address - Street 1:1921 W HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85704-7806
Practice Address - Country:US
Practice Address - Phone:520-544-5210
Practice Address - Fax:520-544-5355
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN053461363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ790795Medicaid
AZ790795Medicaid
AZ74988Medicare ID - Type Unspecified