| NPI | 1689337784 |
|---|---|
| Former Name | MIKENZIE LANE |
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NE 2634) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2021-10-16 |
| Last Update Date | 2025-01-31 |