Provider Demographics
NPI:1245060367
Name:TUPA, LANE
Entity type:Individual
Prefix:
First Name:LANE
Middle Name:
Last Name:TUPA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12100 RAINWOOD RD APT 38
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72212-3936
Mailing Address - Country:US
Mailing Address - Phone:870-678-3141
Mailing Address - Fax:
Practice Address - Street 1:700 W FOREST AVE FL 5
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38301-3937
Practice Address - Country:US
Practice Address - Phone:731-541-3755
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-05
Last Update Date:2025-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program