Provider Demographics
NPI:1699449082
Name:LANGE, JASON ALEXANDER
Entity type:Individual
Prefix:MR
First Name:JASON
Middle Name:ALEXANDER
Last Name:LANGE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:48 AVON ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04101-2364
Mailing Address - Country:US
Mailing Address - Phone:646-369-8785
Mailing Address - Fax:
Practice Address - Street 1:43 SOKOKIS TRL
Practice Address - Street 2:
Practice Address - City:EAST WATERBORO
Practice Address - State:ME
Practice Address - Zip Code:04030-5400
Practice Address - Country:US
Practice Address - Phone:207-247-6742
Practice Address - Fax:207-247-6114
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-09
Last Update Date:2024-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR202105402NP-PP363LF0000X
MECNP211177363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily