MEDICARE: LANCE L LANE PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	085001883	IL
2	363A00000X	Physician Assistant	085001883	IL

General Provider Information

NPI Number	:	1023088655
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LANCE L LANE PA-C

Provider Business Mailing Address
First Line	:	4700 MEMORIAL DR STE 210
Second Line	:
City	:	BELLEVILLE
State	:	IL
Zip	:	62226-5373
Country	:	US
Telephone Number	:	618-767-7700
Fax Number	:

Provider Business Practice Location Address
First Line	:	4700 MEMORIAL DR STE 210
Second Line	:
City	:	BELLEVILLE
State	:	IL
Zip	:	62226-5373
Country	:	US
Telephone Number	:	618-767-7700
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/25/2006
Last Update Date	:	05/16/2023

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Directions to “ LANCE L LANE PA-C” Practice Location

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