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General NPI Number Information
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NPI Number | 1669415188
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Entity Type | Individual
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Provider Name | MICHAEL J LANE PA-C
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Gender | Male
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Dates
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Enumeration Date | 06/13/2006
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Last Update Date | 12/05/2014
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Provider Practice Location Address
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Address Line | 388 E. PARKCENTER BLVD.
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City | BOISE
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State | ID
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Zip | 83706
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Country | US
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Telephone | 208-424-9101
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Fax | 208-424-5072
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Provider Business Mailing Address
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Address Line | PO BOX 1603
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City | BOISE
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State | ID
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Zip | 83701-1603
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Country | US
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Telephone | 208-424-9101
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Fax | 208-424-5072
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | PA377
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License Number State | ID
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Taxonomy #2
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number | M7247
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License Number State | ID
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