Provider Demographics
NPI:1144549379
Name:LANE, SAMANTHA COLLEEN (IDC)
Entity type:Individual
Prefix:MISS
First Name:SAMANTHA
Middle Name:COLLEEN
Last Name:LANE
Suffix:
Gender:F
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34800 BOB WILSON DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92134-1098
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2000 W MARINE VIEW DR # 2134
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98207-2900
Practice Address - Country:US
Practice Address - Phone:425-304-4343
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-27
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman
No171000000XOther Service ProvidersMilitary Health Care Provider