MEDICARE: MR. W. D. PETER LANE LMT CNMT

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	171W00000X	Contractor	1636	NM

General Provider Information

NPI Number	:	1710182357
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. W. D. PETER LANE LMT CNMT

Provider Business Mailing Address
First Line	:	78 KIVA PL
Second Line	:
City	:	SANDIA PARK
State	:	NM
Zip	:	87047-8510
Country	:	US
Telephone Number	:	505-688-6732
Fax Number	:

Provider Business Practice Location Address
First Line	:	8005 PENNSYLVANIA CIR NE
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87110-7810
Country	:	US
Telephone Number	:	505-248-0698
Fax Number	:

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

Provider Enumeration Date	:	06/15/2007
Last Update Date	:	07/08/2007

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