Provider Demographics
NPI:1023088655
Name:LANE, LANCE L (PA-C)
Entity type:Individual
Prefix:
First Name:LANCE
Middle Name:L
Last Name:LANE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4700 MEMORIAL DR STE 210
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62226-5373
Mailing Address - Country:US
Mailing Address - Phone:618-767-7700
Mailing Address - Fax:
Practice Address - Street 1:4700 MEMORIAL DR STE 210
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62226-5373
Practice Address - Country:US
Practice Address - Phone:618-767-7700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2023-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085001883363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP80840Medicare UPIN
IL280438Medicare ID - Type Unspecified
ILIL3374027Medicare PIN