Provider Demographics
NPI:1598997207
Name:LONG, KENNETH ALAN
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:ALAN
Last Name:LONG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 458
Mailing Address - Street 2:
Mailing Address - City:ORTING
Mailing Address - State:WA
Mailing Address - Zip Code:98360-0458
Mailing Address - Country:US
Mailing Address - Phone:360-897-8300
Mailing Address - Fax:360-897-8302
Practice Address - Street 1:16817 223RD AVE E
Practice Address - Street 2:
Practice Address - City:ORTING
Practice Address - State:WA
Practice Address - Zip Code:98360-9120
Practice Address - Country:US
Practice Address - Phone:360-897-8300
Practice Address - Fax:360-897-8302
Is Sole Proprietor?:No
Enumeration Date:2009-08-13
Last Update Date:2009-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA602 876 041171R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171R00000XOther Service ProvidersInterpreter
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7144942OtherWASHINGTON PROVIDER NUMBER