Healthcare Provider Details

I. General information

NPI: 1104801315
Provider Name (Legal Business Name): SCOTT ALAN LANGE PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/09/2005
Last Update Date: 04/08/2022
Certification Date: 04/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1134 N 500 W SUITE 100
PROVO UT
84604-3383
US

IV. Provider business mailing address

PO BOX 27128
SALT LAKE CITY UT
84127-0128
US

V. Phone/Fax

Practice location:
  • Phone: 801-357-7081
  • Fax:
Mailing address:
  • Phone: 801-357-7081
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA00880
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number6224324-1206
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: