Provider Demographics
NPI:1447587027
Name:LONG, JUSTIN ALLEN (PA)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:ALLEN
Last Name:LONG
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 S SANTA FE AVE, SUITE 200
Mailing Address - Street 2:
Mailing Address - City:SALINA
Mailing Address - State:KS
Mailing Address - Zip Code:67401
Mailing Address - Country:US
Mailing Address - Phone:785-452-7562
Mailing Address - Fax:785-452-7105
Practice Address - Street 1:501 S SANTA FE AVE, SUITE 200
Practice Address - Street 2:
Practice Address - City:SALINA
Practice Address - State:KS
Practice Address - Zip Code:67401
Practice Address - Country:US
Practice Address - Phone:785-452-7562
Practice Address - Fax:785-452-7105
Is Sole Proprietor?:No
Enumeration Date:2009-11-03
Last Update Date:2020-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS15-02009363AM0700X
ORPA150409363AS0400X
KS1502009363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS201166150AMedicaid