Provider Demographics
NPI:1346743911
Name:LONG, KATHLEEN (PA)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:LONG
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1822 S LOGAN ST
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80210-3126
Mailing Address - Country:US
Mailing Address - Phone:720-318-5325
Mailing Address - Fax:
Practice Address - Street 1:2468, 75 NIELSON ST
Practice Address - Street 2:
Practice Address - City:WATSONVILLE
Practice Address - State:CA
Practice Address - Zip Code:95076
Practice Address - Country:US
Practice Address - Phone:831-724-4741
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-09
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA55261363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant