Provider Demographics
NPI:1467593988
Name:LONG, MARNIE LEE (PA-C, MPH)
Entity Type:Individual
Prefix:MRS
First Name:MARNIE
Middle Name:LEE
Last Name:LONG
Suffix:
Gender:F
Credentials:PA-C, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:5208 VENETIAN BLVD NE
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33703-3239
Mailing Address - Country:US
Mailing Address - Phone:727-526-8289
Mailing Address - Fax:727-526-7029
Practice Address - Street 1:1201 5TH AVE N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33705-1400
Practice Address - Country:US
Practice Address - Phone:727-822-6661
Practice Address - Fax:727-823-1334
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLPA9100941363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE2637YMedicare ID - Type Unspecified
FLS81907Medicare UPIN