Basic Information
| Provider Information | |||||||||
| NPI: | 1942568969 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LANE | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | ALEXANDER | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3777 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972083777 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034133900 | ||||||||
| FaxNumber: | 5034133710 | ||||||||
| Practice Location | |||||||||
| Address1: | 1040 NW 22ND AVE | ||||||||
| Address2: | SUITE 420 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972103057 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5039633100 | ||||||||
| FaxNumber: | 5034595398 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/27/2012 | ||||||||
| LastUpdateDate: | 03/26/2018 | ||||||||
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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 | 2084N0400X | MD177213 | OR | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 2059497 | 05 | WA | MEDICAID | 500708914 | 05 | OR | MEDICAID |