Provider Demographics
NPI:1144781576
Name:LONG, KYLE DAVID (PA-C)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:DAVID
Last Name:LONG
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4701 LAKE SHORE DR
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23321-1383
Mailing Address - Country:US
Mailing Address - Phone:757-803-4806
Mailing Address - Fax:
Practice Address - Street 1:825 FAIRFAX AVE UNIT 310
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23507-1914
Practice Address - Country:US
Practice Address - Phone:757-238-4497
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-28
Last Update Date:2022-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110006768363A00000X
VA0110006758363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty