Provider Demographics
NPI:1235117268
Name:LANG, COLLIS HARLAN (CRNA)
Entity Type:Individual
Prefix:MR
First Name:COLLIS
Middle Name:HARLAN
Last Name:LANG
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1225 BRECKINRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94533-8135
Mailing Address - Country:US
Mailing Address - Phone:707-422-6688
Mailing Address - Fax:
Practice Address - Street 1:101 BODIN CIR
Practice Address - Street 2:
Practice Address - City:TRAVIS AFB
Practice Address - State:CA
Practice Address - Zip Code:94535-1809
Practice Address - Country:US
Practice Address - Phone:707-423-3589
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-09
Last Update Date:2021-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN00128774367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered