Healthcare Provider Details

I. General information

NPI: 1871087239
Provider Name (Legal Business Name): JAMES W LANE PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2018
Last Update Date: 07/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

635 N FAIRBANKS CT
CHICAGO IL
60611
US

IV. Provider business mailing address

680 N LAKE SHORE DR STE 1000
CHICAGO IL
60611-8709
US

V. Phone/Fax

Practice location:
  • Phone: 312-694-2273
  • Fax:
Mailing address:
  • Phone: 312-695-0665
  • Fax: 312-695-6594

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: