Healthcare Provider Details

I. General information

NPI: 1699449082
Provider Name (Legal Business Name): MR. JASON ALEXANDER LANGE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2021
Last Update Date: 05/14/2024
Certification Date: 05/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43 SOKOKIS TRL
EAST WATERBORO ME
04030-5400
US

IV. Provider business mailing address

48 AVON ST
PORTLAND ME
04101-2364
US

V. Phone/Fax

Practice location:
  • Phone: 207-247-6742
  • Fax: 207-247-6114
Mailing address:
  • Phone: 646-369-8785
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number202105402NP-PP
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCNP211177
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: