Provider Demographics
NPI:1114228210
Name:LONGO, MICHAEL ANTHONY (RPA-C)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:ANTHONY
Last Name:LONGO
Suffix:
Gender:M
Credentials:RPA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:72 PLEASURE AVE
Mailing Address - Street 2:
Mailing Address - City:LK RONKONKOMA
Mailing Address - State:NY
Mailing Address - Zip Code:11779-4256
Mailing Address - Country:US
Mailing Address - Phone:631-786-6441
Mailing Address - Fax:
Practice Address - Street 1:HSC T12 RM 080
Practice Address - Street 2:
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11794
Practice Address - Country:US
Practice Address - Phone:631-444-1116
Practice Address - Fax:631-444-1535
Is Sole Proprietor?:No
Enumeration Date:2010-11-06
Last Update Date:2018-05-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY014029363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant