Provider Demographics
NPI:1497840326
Name:LONG, MARY K (PA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:K
Last Name:LONG
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:K
Other - Last Name:FALBO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6500 BOWDEN RD STE 103
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-8066
Mailing Address - Country:US
Mailing Address - Phone:904-634-0640
Mailing Address - Fax:904-634-0203
Practice Address - Street 1:2627 RIVERSIDE AVE STE 300
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204-4717
Practice Address - Country:US
Practice Address - Phone:904-634-0640
Practice Address - Fax:904-634-0203
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2020-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA0003154363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2928256-00Medicaid
GA003104619AMedicaid
FL970021360OtherRAILROAD MEDICARE
GA003104619AMedicaid
FL970021360OtherRAILROAD MEDICARE
FLS66366Medicare UPIN
FL2928256-00Medicaid