Basic Information
| Provider Information | |||||||||
| NPI: | 1952483901 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HANSON | ||||||||
| FirstName: | LANE | ||||||||
| MiddleName: | T | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 829 | ||||||||
| Address2: | |||||||||
| City: | BLACKFOOT | ||||||||
| State: | ID | ||||||||
| PostalCode: | 832210829 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2085234906 | ||||||||
| FaxNumber: | 2085232025 | ||||||||
| Practice Location | |||||||||
| Address1: | 98 POPLAR ST | ||||||||
| Address2: | |||||||||
| City: | BLACKFOOT | ||||||||
| State: | ID | ||||||||
| PostalCode: | 832211758 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2087854100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2006 | ||||||||
| LastUpdateDate: | 12/21/2007 | ||||||||
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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 | 367500000X | RNA611 | ID | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | P00168342 | 01 | RAILROAD MEDICARE | OTHER |