Healthcare Provider Details

I. General information

NPI: 1841607678
Provider Name (Legal Business Name): BRIAN SCOTT LANG PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2014
Last Update Date: 12/11/2019
Certification Date: 12/11/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1717 N E ST STE 205
PENSACOLA FL
32501-6336
US

IV. Provider business mailing address

PO BOX 17567
PENSACOLA FL
32522-7567
US

V. Phone/Fax

Practice location:
  • Phone: 850-437-8810
  • Fax: 850-437-8809
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA9107954
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: