Provider Demographics
NPI:1376633685
Name:LONG, STEPHEN
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:
Last Name:LONG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:STEPHEN
Other - Middle Name:
Other - Last Name:LONG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA-C
Mailing Address - Street 1:1700 WADE CIR
Mailing Address - Street 2:
Mailing Address - City:KLAMATH FALLS
Mailing Address - State:OR
Mailing Address - Zip Code:97601-1581
Mailing Address - Country:US
Mailing Address - Phone:541-883-7144
Mailing Address - Fax:
Practice Address - Street 1:1700 WADE CIR
Practice Address - Street 2:
Practice Address - City:KLAMATH FALLS
Practice Address - State:OR
Practice Address - Zip Code:97601-1581
Practice Address - Country:US
Practice Address - Phone:541-883-7144
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA 10921363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical