Provider Demographics
NPI:1689337784
Name:LANE, MIKENZIE (PA-C)
Entity type:Individual
Prefix:
First Name:MIKENZIE
Middle Name:
Last Name:LANE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MIKENZIE
Other - Middle Name:
Other - Last Name:LANE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 3755
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68103-0755
Mailing Address - Country:US
Mailing Address - Phone:102-354-2100
Mailing Address - Fax:402-354-2155
Practice Address - Street 1:11946 STANDING STONE DR
Practice Address - Street 2:
Practice Address - City:GRETNA
Practice Address - State:NE
Practice Address - Zip Code:68028-8094
Practice Address - Country:US
Practice Address - Phone:402-354-2273
Practice Address - Fax:402-815-4510
Is Sole Proprietor?:No
Enumeration Date:2021-10-16
Last Update Date:2025-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
NE2634363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant