=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023087467
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SANDRA EVELYN LANE MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/17/2006
-----------------------------------------------------
Last Update Date | 01/14/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 315 E OLYMPIA AVE UNIT 211
-----------------------------------------------------
City | PUNTA GORDA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33950-3823
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-637-2663
-----------------------------------------------------
Fax | 941-637-6872
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 315 E OLYMPIA AVE UNIT 211
-----------------------------------------------------
City | PUNTA GORDA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33950-3823
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-637-2663
-----------------------------------------------------
Fax | 941-637-6872
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207QS0010X
-----------------------------------------------------
Taxonomy Name | Sports Medicine (Family Medicine) Physician
-----------------------------------------------------
License Number | 35052191
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207QS0010X
-----------------------------------------------------
Taxonomy Name | Sports Medicine (Family Medicine) Physician
-----------------------------------------------------
License Number | ME136355
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------