Provider Demographics
NPI:1609285626
Name:LONG, NICHOLAS (MED, ATC, LAT)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:LONG
Suffix:
Gender:M
Credentials:MED, ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72032-4115
Mailing Address - Country:US
Mailing Address - Phone:501-450-5045
Mailing Address - Fax:
Practice Address - Street 1:1600 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72032-4115
Practice Address - Country:US
Practice Address - Phone:501-450-5045
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-04
Last Update Date:2014-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAT 6112255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer