Healthcare Provider Details

I. General information

NPI: 1619113222
Provider Name (Legal Business Name): WAYNE EMERALD LANG M.T.(ASCP)
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/02/2009
Last Update Date: 01/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7550 WILLIS CREEK RD
WINSTON OR
97496-5555
US

IV. Provider business mailing address

7550 WILLIS CREEK RD
WINSTON OR
97496-5555
US

V. Phone/Fax

Practice location:
  • Phone: 541-863-8900
  • Fax:
Mailing address:
  • Phone: 541-863-8900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246QM0706X
TaxonomyMedical Technologist
License NumberMT 119423
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: