Provider Demographics
NPI:1700200458
Name:LANGE, CARL W IV (PA)
Entity Type:Individual
Prefix:MR
First Name:CARL
Middle Name:W
Last Name:LANGE
Suffix:IV
Gender:M
Credentials:PA
Other - Prefix:MR
Other - First Name:CHIP
Other - Middle Name:
Other - Last Name:LANGE
Other - Suffix:IV
Other - Last Name Type:Other Name
Other - Credentials:PA
Mailing Address - Street 1:1337 S SAM HOUSTON BLVD
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:MO
Mailing Address - Zip Code:65483-2046
Mailing Address - Country:US
Mailing Address - Phone:417-967-5435
Mailing Address - Fax:417-967-5503
Practice Address - Street 1:1337 S SAM HOUSTON BLVD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:MO
Practice Address - Zip Code:65483-2046
Practice Address - Country:US
Practice Address - Phone:417-967-5435
Practice Address - Fax:417-967-5503
Is Sole Proprietor?:No
Enumeration Date:2014-02-14
Last Update Date:2014-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014004500363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1700200458Medicaid
MO26D0889777OtherCLIA
MO268535Medicare Oscar/Certification