Basic Information
| Provider Information | |||||||||
| NPI: | 1699110528 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LANE | ||||||||
| FirstName: | ANTHONY | ||||||||
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| Credential: | OTR | ||||||||
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| Mailing Information | |||||||||
| Address1: | 618 GRIFFIN ST | ||||||||
| Address2: | |||||||||
| City: | CARVER | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553159308 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 4415 W 36 1/2 ST | ||||||||
| Address2: | |||||||||
| City: | ST LOUIS PARK | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554164854 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9529279717 | ||||||||
| FaxNumber: | 9529277687 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/06/2013 | ||||||||
| LastUpdateDate: | 05/06/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 103927 | MN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.