Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207P00000X | Emergency Physician | MD00030715 | WA |
N | 207PE0004X | Emergency Medical Services | M-2099 | GU |
NPI | 1053471102 |
---|---|
Provider Name | Juergen Lang |
First Address | Moscow, ID 83843-2405 |
Second Address | Clarkston, WA 99403 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 11/12/2006 |
Last Update Date | 07/03/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
001083120 | (05) | WA |
003793700 | IDAHO MEDICAID (01) | ID |
F55922 | (02) |