Provider Demographics
NPI:1922037415
Name:LANG, TERESSA (PA-C)
Entity Type:Individual
Prefix:
First Name:TERESSA
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 1:310 TORBETT ST
Mailing Address - Street 2:
Mailing Address - City:RICHLAND
Mailing Address - State:WA
Mailing Address - Zip Code:99354-2604
Mailing Address - Country:US
Mailing Address - Phone:509-946-7646
Mailing Address - Fax:509-946-7666
Practice Address - Street 1:310 TORBETT ST
Practice Address - Street 2:
Practice Address - City:RICHLAND
Practice Address - State:WA
Practice Address - Zip Code:99354-2604
Practice Address - Country:US
Practice Address - Phone:509-946-7646
Practice Address - Fax:509-946-7666
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2010-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2979363A00000X
WA60162619363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ862525Medicaid
AZ101334Medicare ID - Type Unspecified
AZS84027Medicare UPIN