Healthcare Provider Details

I. General information

NPI: 1023369527
Provider Name (Legal Business Name): GREGORY R. LANG PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2012
Last Update Date: 05/03/2022
Certification Date: 05/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 NE MEDICAL CENTER DR
BEND OR
97701-6051
US

IV. Provider business mailing address

PO BOX 6048
BEND OR
97708-6048
US

V. Phone/Fax

Practice location:
  • Phone: 541-382-4900
  • Fax: 541-706-2398
Mailing address:
  • Phone: 541-382-4900
  • Fax: 541-706-2398

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA208709
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: