# MR. MICHAEL J LANE

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- **Entity:** Individual
- **Status:** Active
- **Sole proprietor:** No

## Provider details

- **NPI number:** 1669415188
- **Gender:** Man
- **Credential:** PA-C

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207N00000X | Dermatology Physician | M7247 | ID | — |
| 363A00000X | Physician Assistant | PA377 | ID | Yes |

## Other

- **Enumeration date:** 06/13/2006
- **Last updated:** 12/05/2014

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | 000010140814 | BLUE SHIELD OF ID; BOISE | ID |
| 01 | — | 000010145063 | BLUE SHIELD OF ID; EMMETT | ID |
| 05 | — | 806272300 | — | ID |
| 05 | — | 806272301 | — | ID |
| 01 | — | DI593 | BLUE CROSS OF ID | ID |