Provider Demographics
NPI:1265029581
Name:LONG, MADISON HEBERT (PA-C)
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:HEBERT
Last Name:LONG
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4501 192ND ST FL 1
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11358-3435
Mailing Address - Country:US
Mailing Address - Phone:774-641-3966
Mailing Address - Fax:
Practice Address - Street 1:1991 MARCUS AVE STE 300
Practice Address - Street 2:
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11042-2058
Practice Address - Country:US
Practice Address - Phone:516-719-3376
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-22
Last Update Date:2023-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY028519363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty