Healthcare Provider Details

I. General information

NPI: 1710182357
Provider Name (Legal Business Name): W. D. PETER LANE LMT CNMT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/15/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8005 PENNSYLVANIA CIR NE
ALBUQUERQUE NM
87110-7810
US

IV. Provider business mailing address

78 KIVA PL
SANDIA PARK NM
87047-8510
US

V. Phone/Fax

Practice location:
  • Phone: 505-248-0698
  • Fax:
Mailing address:
  • Phone: 505-688-6732
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number1636
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: