Provider Demographics
NPI:1194078360
Name:LANE, MICHAEL JEFFERY (ATP)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JEFFERY
Last Name:LANE
Suffix:
Gender:M
Credentials:ATP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1622 BELLROSE DR
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70815-5433
Mailing Address - Country:US
Mailing Address - Phone:504-210-9293
Mailing Address - Fax:877-723-6236
Practice Address - Street 1:10632 ALCO AVE
Practice Address - Street 2:UNIT 1
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70816-4238
Practice Address - Country:US
Practice Address - Phone:866-795-4825
Practice Address - Fax:877-723-6236
Is Sole Proprietor?:No
Enumeration Date:2012-10-24
Last Update Date:2012-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILATP 2652247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other