Healthcare Provider Details

I. General information

NPI: 1245410422
Provider Name (Legal Business Name): KRISTINE CARTA LANE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/06/2007
Last Update Date: 11/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

540 SAYBROOK RD STE 110
MIDDLETOWN CT
06457-4711
US

IV. Provider business mailing address

15 TRAILSIDE XING
MIDDLETOWN CT
06457-5465
US

V. Phone/Fax

Practice location:
  • Phone: 860-740-2280
  • Fax:
Mailing address:
  • Phone: 860-559-8460
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number001986
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: