Provider Demographics
NPI:1417912494
Name:LANG, JENNIFER (PA-C)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:LANG
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 1:1130 S HARBOR CITY BLVD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-1966
Mailing Address - Country:US
Mailing Address - Phone:321-914-4211
Mailing Address - Fax:321-914-4212
Practice Address - Street 1:1130 S HARBOR CITY BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-1966
Practice Address - Country:US
Practice Address - Phone:321-914-4211
Practice Address - Fax:321-914-4212
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2011-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9102077363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL291338100Medicaid
S56904Medicare UPIN