Provider Demographics
NPI:1104022185
Name:LONG, PAMELA DIAN (PA)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:DIAN
Last Name:LONG
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4560 SE INTERNATIONAL WAY STE 100
Mailing Address - Street 2:
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97222-4628
Mailing Address - Country:US
Mailing Address - Phone:971-206-5179
Mailing Address - Fax:
Practice Address - Street 1:4560 SE INTERNATIONAL WAY STE 100
Practice Address - Street 2:
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97222-4628
Practice Address - Country:US
Practice Address - Phone:971-206-5179
Practice Address - Fax:503-905-0495
Is Sole Proprietor?:No
Enumeration Date:2007-06-26
Last Update Date:2020-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA00611363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500640462Medicaid
ORR161931Medicare PIN