Provider Demographics
NPI:1093103038
Name:LANGE, BROOKE A (PA-C)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:A
Last Name:LANGE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 636930
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-6930
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:830 W HIGH ST STE 360
Practice Address - Street 2:
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45801-3985
Practice Address - Country:US
Practice Address - Phone:419-227-7117
Practice Address - Fax:419-227-2848
Is Sole Proprietor?:No
Enumeration Date:2014-12-29
Last Update Date:2020-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.004109363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0116351Medicaid
OH9943723OtherMEDICARE GROUP PTAN
OH1184652539OtherGROUP NPI
OH0105065OtherMEDICAID GROUP
OH0116351Medicaid
OHH428420Medicare PIN