Provider Demographics
NPI:1841258548
Name:LANE, MONA LISA (DO)
Entity type:Individual
Prefix:DR
First Name:MONA
Middle Name:LISA
Last Name:LANE
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Gender:F
Credentials:DO
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Mailing Address - Street 1:4140 HERITAGE TRACE PKWY
Mailing Address - Street 2:SUITE 312
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76244-5310
Mailing Address - Country:US
Mailing Address - Phone:817-741-7353
Mailing Address - Fax:817-741-7501
Practice Address - Street 1:4140 HERITAGE TRACE PKWY
Practice Address - Street 2:SUITE 312
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76244-5310
Practice Address - Country:US
Practice Address - Phone:817-741-7353
Practice Address - Fax:817-741-7501
Is Sole Proprietor?:No
Enumeration Date:2006-05-02
Last Update Date:2012-06-13
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Provider Licenses
StateLicense IDTaxonomies
TXJ3288207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXG53058Medicare UPIN