Provider Demographics
NPI:1588680847
Name:LANG, MARY (NP)
Entity Type:Individual
Prefix:PROF
First Name:MARY
Middle Name:
Last Name:LANG
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2665 RIDGEWAY AVE
Mailing Address - Street 2:SUITE 460
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14626-4296
Mailing Address - Country:US
Mailing Address - Phone:585-581-6790
Mailing Address - Fax:585-581-6793
Practice Address - Street 1:2665 RIDGEWAY AVE
Practice Address - Street 2:SUITE 460
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14626
Practice Address - Country:US
Practice Address - Phone:585-581-6790
Practice Address - Fax:585-581-6793
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2016-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF301226363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03299992Medicaid
NYJ400039293/GRP70008AMedicare PIN
NYJ400039273/GRPBA0017Medicare PIN