Provider Demographics
NPI:1093707945
Name:LONG, MATTHEW S (CRNA)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:S
Last Name:LONG
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:17C BRENTSHIRE SQUARE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-2273
Mailing Address - Country:US
Mailing Address - Phone:731-664-1717
Mailing Address - Fax:731-664-7114
Practice Address - Street 1:17C BRENTSHIRE SQUARE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-2273
Practice Address - Country:US
Practice Address - Phone:731-664-1717
Practice Address - Fax:731-664-7114
Is Sole Proprietor?:No
Enumeration Date:2005-08-17
Last Update Date:2020-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNRN0000067803163W00000X
TNRN0000057803163W00000X
TNAPN0000009329367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3607376Medicaid
TN1521318Medicaid