Healthcare Provider Details

I. General information

NPI: 1639156631
Provider Name (Legal Business Name): LAURIE GENE LANE PC-C
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/30/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

308 MAIN ST
OLATHE CO
81425
US

IV. Provider business mailing address

PO BOX 529
OLATHE CO
81425-0529
US

V. Phone/Fax

Practice location:
  • Phone: 970-323-6141
  • Fax: 970-249-8421
Mailing address:
  • Phone: 970-323-6141
  • Fax: 970-249-8421

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number142
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: