Provider Demographics
NPI:1922024819
Name:LANGE-VANDELLO, ERIN (PAC MS)
Entity Type:Individual
Prefix:
First Name:ERIN
Middle Name:
Last Name:LANGE-VANDELLO
Suffix:
Gender:F
Credentials:PAC MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38135 MARKET SQ
Mailing Address - Street 2:
Mailing Address - City:ZEPHYRHILLS
Mailing Address - State:FL
Mailing Address - Zip Code:33542-7505
Mailing Address - Country:US
Mailing Address - Phone:813-528-4975
Mailing Address - Fax:
Practice Address - Street 1:15285 AMBERLY DR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33647
Practice Address - Country:US
Practice Address - Phone:813-979-6978
Practice Address - Fax:813-975-0534
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2014-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9102580363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q00817Medicare UPIN
FLPA9102580OtherLICENSE #