Basic Information
| Provider Information | |||||||||
| NPI: | 1699793265 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LANGE | ||||||||
| FirstName: | MARSHA | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2401 DEMERS AVE | ||||||||
| Address2: | |||||||||
| City: | GRAND FORKS | ||||||||
| State: | ND | ||||||||
| PostalCode: | 58201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7017801891 | ||||||||
| FaxNumber: | 7015876009 | ||||||||
| Practice Location | |||||||||
| Address1: | 607 DEMERS AVE | ||||||||
| Address2: | |||||||||
| City: | EAST GRAND FORKS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 567211833 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187730357 | ||||||||
| FaxNumber: | 2187732994 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2006 | ||||||||
| LastUpdateDate: | 07/31/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 5823 | ND | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 52278 | MN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 5823 | 01 | ND | NORTH DAKOTA STATE MEDICAL LICENSE | OTHER |