Healthcare Provider Details

I. General information

NPI: 1588209837
Provider Name (Legal Business Name): KATHRYN LYNN LANE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/11/2019
Last Update Date: 06/29/2021
Certification Date: 06/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5401 N PORTLAND AVE STE 600
OKLAHOMA CITY OK
73112-2121
US

IV. Provider business mailing address

3007 LADYBANK LN
NORMAN OK
73072-1955
US

V. Phone/Fax

Practice location:
  • Phone: 405-713-9940
  • Fax: 405-713-9941
Mailing address:
  • Phone: 405-713-9940
  • Fax: 405-713-9941

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number3100
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: