Provider Demographics
NPI:1508167644
Name:LONG, DESIREE L (PA)
Entity Type:Individual
Prefix:
First Name:DESIREE
Middle Name:L
Last Name:LONG
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:DESIREE
Other - Middle Name:L
Other - Last Name:WOODS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5496 E TAFT RD
Mailing Address - Street 2:
Mailing Address - City:NORTH SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13212-3784
Mailing Address - Country:US
Mailing Address - Phone:315-552-6700
Mailing Address - Fax:315-552-6701
Practice Address - Street 1:5496 E TAFT RD
Practice Address - Street 2:
Practice Address - City:NORTH SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13212-3784
Practice Address - Country:US
Practice Address - Phone:315-552-6700
Practice Address - Fax:315-552-6701
Is Sole Proprietor?:No
Enumeration Date:2010-11-05
Last Update Date:2013-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014364363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant