Provider Demographics
NPI:1497475206
Name:LONGE, REBECKA J (PA)
Entity Type:Individual
Prefix:
First Name:REBECKA
Middle Name:J
Last Name:LONGE
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 1:2335 HOLLYBUSH RD
Mailing Address - Street 2:
Mailing Address - City:MEDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55340-9470
Mailing Address - Country:US
Mailing Address - Phone:763-350-7800
Mailing Address - Fax:
Practice Address - Street 1:1221 S GEAR AVE
Practice Address - Street 2:
Practice Address - City:WEST BURLINGTON
Practice Address - State:IA
Practice Address - Zip Code:52655-1679
Practice Address - Country:US
Practice Address - Phone:131-976-8100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-31
Last Update Date:2022-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA114806363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant