Provider Demographics
NPI:1134146137
Name:LONG, KAREN W (MMS-PA-C)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:W
Last Name:LONG
Suffix:
Gender:F
Credentials:MMS-PA-C
Other - Prefix:
Other - First Name:KAREN
Other - Middle Name:M
Other - Last Name:WIEDEMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MMS-PA-C
Mailing Address - Street 1:2750 CLAY EDWARDS DR
Mailing Address - Street 2:SUITE 410
Mailing Address - City:NORTH KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64116-3237
Mailing Address - Country:US
Mailing Address - Phone:816-471-8114
Mailing Address - Fax:816-842-5342
Practice Address - Street 1:2750 CLAY EDWARDS DR
Practice Address - Street 2:SUITE 410
Practice Address - City:NORTH KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64116-3237
Practice Address - Country:US
Practice Address - Phone:816-471-8114
Practice Address - Fax:816-842-5342
Is Sole Proprietor?:No
Enumeration Date:2006-07-16
Last Update Date:2012-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPA180510363A00000X
CAPA18051363AS0400X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0PA180510Medicare ID - Type Unspecified
CAQ61218Medicare UPIN