Provider Demographics
NPI:1912579996
Name:KOCOVSKY, LANE R (FNP)
Entity type:Individual
Prefix:
First Name:LANE
Middle Name:R
Last Name:KOCOVSKY
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15245 BLUEBIRD ST NW
Mailing Address - Street 2:
Mailing Address - City:ANDOVER
Mailing Address - State:MN
Mailing Address - Zip Code:55304-3538
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15245 BLUEBIRD ST NW
Practice Address - Street 2:
Practice Address - City:ANDOVER
Practice Address - State:MN
Practice Address - Zip Code:55304-3538
Practice Address - Country:US
Practice Address - Phone:763-587-4688
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-11
Last Update Date:2024-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ01169000363LF0000X
MN11225363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily