Provider Demographics
NPI:1083686901
Name:LONG, GENEVIEVE A (PA-C)
Entity Type:Individual
Prefix:
First Name:GENEVIEVE
Middle Name:A
Last Name:LONG
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:GENEVIEVE
Other - Middle Name:A
Other - Last Name:HARRIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4510 BROCKTON AVE STE 365
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92501-4020
Mailing Address - Country:US
Mailing Address - Phone:844-827-8000
Mailing Address - Fax:951-403-2803
Practice Address - Street 1:4510 BROCKTON AVE STE 365
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92501
Practice Address - Country:US
Practice Address - Phone:844-827-8000
Practice Address - Fax:951-403-2803
Is Sole Proprietor?:No
Enumeration Date:2006-02-03
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0014-04114363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHPA78751Medicare ID - Type Unspecified
OHS96452Medicare UPIN