Provider Demographics
NPI:1245227875
Name:LONGWORTH, JUDITH C (FNP)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:C
Last Name:LONGWORTH
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:740 S ALAMO
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78205-3437
Mailing Address - Country:US
Mailing Address - Phone:210-222-0333
Mailing Address - Fax:210-222-0369
Practice Address - Street 1:740 S ALAMO
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78205-3437
Practice Address - Country:US
Practice Address - Phone:210-222-0333
Practice Address - Fax:210-222-0369
Is Sole Proprietor?:No
Enumeration Date:2005-09-29
Last Update Date:2011-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX633826363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX160866301Medicaid
P97322Medicare UPIN
TX8B1284Medicare ID - Type Unspecified