Provider Demographics
NPI:1639511157
Name:LONGAN, TESSA LYNN (APRN-CNP)
Entity Type:Individual
Prefix:
First Name:TESSA
Middle Name:LYNN
Last Name:LONGAN
Suffix:
Gender:F
Credentials:APRN-CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:5300 N INDEPENDENCE AVE
Mailing Address - Street 2:280
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-5556
Mailing Address - Country:US
Mailing Address - Phone:918-786-2720
Mailing Address - Fax:918-786-8020
Practice Address - Street 1:900 E 13TH ST
Practice Address - Street 2:SUITE 205
Practice Address - City:GROVE
Practice Address - State:OK
Practice Address - Zip Code:74344-2975
Practice Address - Country:US
Practice Address - Phone:918-786-2720
Practice Address - Fax:918-786-8020
Is Sole Proprietor?:No
Enumeration Date:2013-07-25
Last Update Date:2017-04-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK83227363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200468380XMedicaid
OK200504950AMedicaid
OK900522214Medicare PIN