Provider Demographics
NPI:1750631156
Name:LANG, ELISA NICOLE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:ELISA
Middle Name:NICOLE
Last Name:LANG
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:ELISA
Other - Middle Name:NICOLE
Other - Last Name:GULLION
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1735 27TH ST
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:OH
Mailing Address - Zip Code:45662-2677
Mailing Address - Country:US
Mailing Address - Phone:740-356-8681
Mailing Address - Fax:740-353-7900
Practice Address - Street 1:835 W EMMITT AVE
Practice Address - Street 2:
Practice Address - City:WAVERLY
Practice Address - State:OH
Practice Address - Zip Code:45690-1190
Practice Address - Country:US
Practice Address - Phone:740-947-7662
Practice Address - Fax:740-941-0099
Is Sole Proprietor?:No
Enumeration Date:2012-09-12
Last Update Date:2023-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.003575RX363A00000X
OH50.003575363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant