Provider Demographics
NPI:1043785264
Name:LONG, CHRISTIAN
Entity Type:Individual
Prefix:
First Name:CHRISTIAN
Middle Name:
Last Name:LONG
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 1:801 SCHULTZ PL
Mailing Address - Street 2:
Mailing Address - City:MONONA
Mailing Address - State:WI
Mailing Address - Zip Code:53716-2013
Mailing Address - Country:US
Mailing Address - Phone:608-514-6102
Mailing Address - Fax:
Practice Address - Street 1:WATERTOWN REGIONAL MEDICAL CENTER
Practice Address - Street 2:1684 S CHURCH ST
Practice Address - City:WATERTOWN
Practice Address - State:WI
Practice Address - Zip Code:53094
Practice Address - Country:US
Practice Address - Phone:920-262-4220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-04
Last Update Date:2018-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11437-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist