Provider Demographics
NPI:1528498466
Name:LANE, AISHA
Entity type:Individual
Prefix:
First Name:AISHA
Middle Name:
Last Name:LANE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6801 W 73RD ST UNIT 922
Mailing Address - Street 2:
Mailing Address - City:BEDFORD PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60499-5332
Mailing Address - Country:US
Mailing Address - Phone:708-612-3956
Mailing Address - Fax:
Practice Address - Street 1:7900 W 75TH ST
Practice Address - Street 2:
Practice Address - City:BRIDGEVIEW
Practice Address - State:IL
Practice Address - Zip Code:60455-1237
Practice Address - Country:US
Practice Address - Phone:708-612-3956
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-13
Last Update Date:2019-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL238000384246ZC0007X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
No246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL246ZC0007XOtherTAXONOMY #