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NPI Code Detail

MEDICARE: BRANDON KEITH LANE

MEDICARE: BRANDON KEITH LANE
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
1175T00000XPeer Specialist

General Provider Information

NPI Number : 1649048448
Entity Type Code : Individual
Provider Name (Legal Business Name) : BRANDON KEITH LANE
Provider Business Mailing Address
First Line : 3804 N JUNEAU ST
Second Line :
City : PORTLAND
State : OR
Zip : 97217-7427
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 6828 SE HOLGATE BLVD
Second Line :
City : PORTLAND
State : OR
Zip : 97206-3504
Country : US
Telephone Number : 503-332-4969
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 12/12/2023
Last Update Date : 12/12/2023

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Directions to “ BRANDON KEITH LANE ” Practice Location

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