Provider Demographics
NPI:1073282802
Name:LANG, MALLORY
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:LANG
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 1:18 RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:SAUGERTIES
Mailing Address - State:NY
Mailing Address - Zip Code:12477-4433
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2976 ROUTE 9W
Practice Address - Street 2:
Practice Address - City:SAUGERTIES
Practice Address - State:NY
Practice Address - Zip Code:12477-5234
Practice Address - Country:US
Practice Address - Phone:518-264-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-07
Last Update Date:2021-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant