Provider Demographics
NPI:1326380544
Name:LANE, MEGAN (PA,)
Entity type:Individual
Prefix:
First Name:MEGAN
Middle Name:
Last Name:LANE
Suffix:
Gender:
Credentials:PA,
Other - Prefix:
Other - First Name:MEGAN
Other - Middle Name:
Other - Last Name:TINDAL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA,
Mailing Address - Street 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1210 NW 16TH ST
Practice Address - Street 2:
Practice Address - City:FRUITLAND
Practice Address - State:ID
Practice Address - Zip Code:83619-2202
Practice Address - Country:US
Practice Address - Phone:208-452-8600
Practice Address - Fax:208-452-8601
Is Sole Proprietor?:No
Enumeration Date:2013-03-26
Last Update Date:2025-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0858363A00000X
IDPA-1350363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant