Healthcare Provider Details

I. General information

NPI: 1750631156
Provider Name (Legal Business Name): ELISA NICOLE LANG PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ELISA NICOLE GULLION PA-C

II. Dates (important events)

Enumeration Date: 09/12/2012
Last Update Date: 11/14/2023
Certification Date: 11/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

835 W EMMITT AVE
WAVERLY OH
45690-1190
US

IV. Provider business mailing address

1735 27TH ST
PORTSMOUTH OH
45662-2677
US

V. Phone/Fax

Practice location:
  • Phone: 740-947-7662
  • Fax: 740-941-0099
Mailing address:
  • Phone: 740-356-8681
  • Fax: 740-353-7900

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50.003575RX
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: