Provider Demographics
NPI:1407307077
Name:LANGE, VANESSA (PA-C)
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:
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 1:920 E 28TH ST
Mailing Address - Street 2:SUITE 700
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55407-1139
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:500 HARVARD ST SE STE 7445
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55455-0363
Practice Address - Country:US
Practice Address - Phone:612-273-0883
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-19
Last Update Date:2022-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN12248207RX0202X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1407307077Medicaid