Provider Demographics
NPI:1912280108
Name:ERICKSON, LANE (RN, ACNS-BC)
Entity Type:Individual
Prefix:
First Name:LANE
Middle Name:
Last Name:ERICKSON
Suffix:
Gender:M
Credentials:RN, ACNS-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6400 LAKESHORE DR
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75214-3737
Mailing Address - Country:US
Mailing Address - Phone:512-529-9676
Mailing Address - Fax:
Practice Address - Street 1:4001 W 15TH ST
Practice Address - Street 2:SUITE 290
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75093-5841
Practice Address - Country:US
Practice Address - Phone:469-443-0925
Practice Address - Fax:469-443-0933
Is Sole Proprietor?:No
Enumeration Date:2011-09-23
Last Update Date:2014-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX775751364SA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXTXB143547Medicare PIN
TX322258YWDKMedicare PIN
TXTXB143548Medicare PIN
TX322258YWDLMedicare PIN