Provider Demographics
NPI:1194041590
Name:LONGEST, JANE A (PA)
Entity Type:Individual
Prefix:
First Name:JANE
Middle Name:A
Last Name:LONGEST
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:JANE
Other - Middle Name:A
Other - Last Name:KIRWAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 3177
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21802-3177
Mailing Address - Country:US
Mailing Address - Phone:410-548-2343
Mailing Address - Fax:844-332-3891
Practice Address - Street 1:9715 HEALTHWAY DR
Practice Address - Street 2:
Practice Address - City:BERLIN
Practice Address - State:MD
Practice Address - Zip Code:21811
Practice Address - Country:US
Practice Address - Phone:410-548-2343
Practice Address - Fax:844-332-3891
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-12
Last Update Date:2019-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC5-0000817363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
DEC5-0000817OtherPROFESSIONAL -PHYSICIAN ASSISTANT