Healthcare Provider Details

I. General information

NPI: 1639407752
Provider Name (Legal Business Name): NICHALAS FRANCIS LANE DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2009
Last Update Date: 11/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5111 N SCOTTSDALE RD SUITE #100
SCOTTSDALE AZ
85250-7075
US

IV. Provider business mailing address

5111 N SCOTTSDALE RD SUITE 100
SCOTTSDALE AZ
85250-7075
US

V. Phone/Fax

Practice location:
  • Phone: 480-990-1379
  • Fax: 480-423-8458
Mailing address:
  • Phone: 480-990-1379
  • Fax: 480-423-8458

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number8755
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: