Healthcare Provider Details

I. General information

NPI: 1740042241
Provider Name (Legal Business Name): CRAIG LANE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/29/2024
Last Update Date: 01/29/2024
Certification Date: 01/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

76 VETERANS AVE
BATH NY
14810-0810
US

IV. Provider business mailing address

5590 CRYSTAL SPRINGS RD
DUNDEE NY
14837-9426
US

V. Phone/Fax

Practice location:
  • Phone: 607-664-4000
  • Fax:
Mailing address:
  • Phone: 607-483-4788
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number637559-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: