Provider Demographics
NPI:1932717816
Name:LANE, AMY (PA-C)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:LANE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:
Other - Last Name:FRASER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:9E DR OSMAN BABSON ROAD
Mailing Address - Street 2:
Mailing Address - City:GLOUCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01930-1812
Mailing Address - Country:US
Mailing Address - Phone:978-890-7373
Mailing Address - Fax:978-890-7372
Practice Address - Street 1:9E DR OSMAN BABSON ROAD
Practice Address - Street 2:
Practice Address - City:GLOUCESTER
Practice Address - State:MA
Practice Address - Zip Code:01930-1812
Practice Address - Country:US
Practice Address - Phone:978-890-7373
Practice Address - Fax:978-890-7372
Is Sole Proprietor?:No
Enumeration Date:2020-07-16
Last Update Date:2023-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPA7689363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110163493AMedicaid