=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710182357
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | W. D. PETER LANE LMT CNMT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/15/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8005 PENNSYLVANIA CIR NE
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87110-7810
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-248-0698
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 78 KIVA PL
-----------------------------------------------------
City | SANDIA PARK
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87047-8510
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-688-6732
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171W00000X
-----------------------------------------------------
Taxonomy Name | Contractor
-----------------------------------------------------
License Number | 1636
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------