Provider Demographics
NPI:1437885910
Name:LONG, MICHAEL LAWRENCE
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:LAWRENCE
Last Name:LONG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1320 SMITH ST APT 216
Mailing Address - Street 2:
Mailing Address - City:LOGANSPORT
Mailing Address - State:IN
Mailing Address - Zip Code:46947-1567
Mailing Address - Country:US
Mailing Address - Phone:574-727-1786
Mailing Address - Fax:
Practice Address - Street 1:602 WOODBRIDGE AVE
Practice Address - Street 2:
Practice Address - City:LOGANSPORT
Practice Address - State:IN
Practice Address - Zip Code:46947-1661
Practice Address - Country:US
Practice Address - Phone:574-753-3223
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-27
Last Update Date:2022-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28193730A364SL0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SL0600XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistLong-Term Care