Provider Demographics
NPI:1508808528
Name:LONG, BRENT M (PA)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:M
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 1:2401 PARK DR
Mailing Address - Street 2:STE 101
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17110-9303
Mailing Address - Country:US
Mailing Address - Phone:610-367-2259
Mailing Address - Fax:610-367-0505
Practice Address - Street 1:2401 PARK DR STE 101
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17110-9303
Practice Address - Country:US
Practice Address - Phone:717-686-9842
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2022-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1501096363A00000X, 363AM0700X, 363AS0400X
PAMA001513L363AM0700X
PAOA002700363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200366520AMedicaid
426959Medicare PIN
KSS50942Medicare UPIN