Provider Demographics
NPI:1699760819
Name:LANE, LISA A (MD)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:A
Last Name:LANE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11109 PARKVIEW PLAZA DR # 117
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:125 BAUM STREET
Practice Address - Street 2:
Practice Address - City:AVILLA
Practice Address - State:IN
Practice Address - Zip Code:46710-0698
Practice Address - Country:US
Practice Address - Phone:260-897-3349
Practice Address - Fax:260-897-3650
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-14
Last Update Date:2022-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01046721207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200179590AMedicaid
IN000000570556OtherANTHEM
INP00354178OtherRAILROAD MEDICARE
IN000000364996OtherANTHEM
INP00354178OtherRAILROAD MEDICARE
IN200179590AMedicaid
IN069860NNNNMedicare PIN
IN070860VMedicare PIN