Basic Information
| Provider Information | |||||||||
| NPI: | 1790890200 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LANG | ||||||||
| FirstName: | GORDON | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 HAZEL AVE | ||||||||
| Address2: | |||||||||
| City: | WAKEENEY | ||||||||
| State: | KS | ||||||||
| PostalCode: | 676721538 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 333 N 14TH ST | ||||||||
| Address2: | |||||||||
| City: | WAKEENEY | ||||||||
| State: | KS | ||||||||
| PostalCode: | 676723000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7857432124 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/21/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | 04-20739 | KS | Y | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 105315 | 01 | KS | BCBS EFCC RHC | OTHER | 104716 | 01 | KS | BCBS WFCC RHC | OTHER |