Basic Information
| Provider Information | |||||||||
| NPI: | 1477817047 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LANG | ||||||||
| FirstName: | ANNA | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 112 ASH ST | ||||||||
| Address2: | |||||||||
| City: | SPOONER | ||||||||
| State: | WI | ||||||||
| PostalCode: | 548011487 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7156353979 | ||||||||
| FaxNumber: | 7156353990 | ||||||||
| Practice Location | |||||||||
| Address1: | 112 ASH ST | ||||||||
| Address2: | |||||||||
| City: | SPOONER | ||||||||
| State: | WI | ||||||||
| PostalCode: | 54801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7156353979 | ||||||||
| FaxNumber: | 7156353990 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2012 | ||||||||
| LastUpdateDate: | 12/14/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 10350 | TN | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 12047-024 | WI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 1477817047 | 05 | WI | MEDICAID |