Provider Demographics
NPI:1043239775
Name:LONG, MICHAEL ARLIN (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ARLIN
Last Name:LONG
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450 4TH ST.
Mailing Address - Street 2:PO BOX 367
Mailing Address - City:DASSEL
Mailing Address - State:MN
Mailing Address - Zip Code:55325
Mailing Address - Country:US
Mailing Address - Phone:320-275-3358
Mailing Address - Fax:
Practice Address - Street 1:450 4TH ST.
Practice Address - Street 2:
Practice Address - City:DASSEL
Practice Address - State:MN
Practice Address - Zip Code:55325
Practice Address - Country:US
Practice Address - Phone:320-275-3358
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9836363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN891487700Medicaid
MN891487700Medicaid
MN970001943Medicare ID - Type Unspecified