Provider Demographics
NPI:1063772184
Name:TWO LANES LLC
Entity type:Organization
Organization Name:TWO LANES LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:A
Authorized Official - Last Name:LANE
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-C
Authorized Official - Phone:503-581-1198
Mailing Address - Street 1:1655 STATE ST
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-4232
Mailing Address - Country:US
Mailing Address - Phone:503-581-1198
Mailing Address - Fax:503-339-9565
Practice Address - Street 1:1655 STATE ST
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-4232
Practice Address - Country:US
Practice Address - Phone:503-581-1198
Practice Address - Fax:503-339-9565
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-22
Last Update Date:2022-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201150144NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500653285Medicaid