Provider Demographics
NPI:1104801315
Name:LANGE, SCOTT ALAN (PA)
Entity type:Individual
Prefix:MR
First Name:SCOTT
Middle Name:ALAN
Last Name:LANGE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 27128
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0128
Mailing Address - Country:US
Mailing Address - Phone:801-357-7081
Mailing Address - Fax:
Practice Address - Street 1:1134 N 500 W
Practice Address - Street 2:SUITE 100
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-3383
Practice Address - Country:US
Practice Address - Phone:801-357-7081
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-09
Last Update Date:2022-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA00880363AS0400X
UT6224324-1206363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000068850Medicare PIN
ORP69243Medicare UPIN
UT000063369Medicare PIN
UT5421450001Medicare NSC