Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | 43326 | WI |
NPI | 1003840372 |
---|---|
Provider Name | Kirk Lane |
First Address | Black River Falls, WI 54615-9010 |
Second Address | Black River Falls, WI 54615-9010 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 10/07/2006 |
Last Update Date | 07/12/2009 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
34097800 | (05) | WI |
H39650 | (02) |