Healthcare Provider Details

I. General information

NPI: 1518733070
Provider Name (Legal Business Name): SAMANTHA TATE LANG PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/27/2023
Last Update Date: 10/16/2024
Certification Date: 10/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6330 ORCHARD LAKE RD STE 120
WEST BLOOMFIELD MI
48322-2398
US

IV. Provider business mailing address

43900 GARFIELD RD STE 100
CLINTON TOWNSHIP MI
48038-1137
US

V. Phone/Fax

Practice location:
  • Phone: 248-462-6045
  • Fax:
Mailing address:
  • Phone: 586-286-0112
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601012470
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: