Basic Information
| Provider Information | |||||||||
| NPI: | 1922037415 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LANG | ||||||||
| FirstName: | TERESSA | ||||||||
| MiddleName: | |||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 310 TORBETT ST | ||||||||
| Address2: | |||||||||
| City: | RICHLAND | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993542604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5099467646 | ||||||||
| FaxNumber: | 5099467666 | ||||||||
| Practice Location | |||||||||
| Address1: | 310 TORBETT ST | ||||||||
| Address2: | |||||||||
| City: | RICHLAND | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993542604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5099467646 | ||||||||
| FaxNumber: | 5099467666 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2006 | ||||||||
| LastUpdateDate: | 07/13/2010 | ||||||||
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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 | 363A00000X | 2979 | AZ | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 60162619 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 862525 | 05 | AZ | MEDICAID |