Provider Demographics
NPI:1376084327
Name:LANGE, KRISTOPHER ROBERT (DO)
Entity Type:Individual
Prefix:
First Name:KRISTOPHER
Middle Name:ROBERT
Last Name:LANGE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:745 W 500 N
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84601-2614
Mailing Address - Country:US
Mailing Address - Phone:801-921-2770
Mailing Address - Fax:
Practice Address - Street 1:620 JOHN PAUL JONES CIRCLE
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23708
Practice Address - Country:US
Practice Address - Phone:757-953-0669
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-10
Last Update Date:2023-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MO2022048812207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program