Basic Information
| Provider Information | |||||||||
| NPI: | 1962023820 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LANE | ||||||||
| FirstName: | PAUL | ||||||||
| MiddleName: | RYAN | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4101 N WATER TOWER PL | ||||||||
| Address2: | |||||||||
| City: | MOUNT VERNON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 628646296 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182446222 | ||||||||
| FaxNumber: | 6182461247 | ||||||||
| Practice Location | |||||||||
| Address1: | 4101 N WATER TOWER PL | ||||||||
| Address2: | |||||||||
| City: | MOUNT VERNON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 628646296 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182446222 | ||||||||
| FaxNumber: | 6182461247 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2020 | ||||||||
| LastUpdateDate: | 12/18/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/07/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 085.007905 | IL | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.