Provider Demographics
NPI:1710243217
Name:LONGENECKER, FELICIA (MD)
Entity Type:Individual
Prefix:DR
First Name:FELICIA
Middle Name:
Last Name:LONGENECKER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2750 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80304-3586
Mailing Address - Country:US
Mailing Address - Phone:303-440-3000
Mailing Address - Fax:
Practice Address - Street 1:2750 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80304-3586
Practice Address - Country:US
Practice Address - Phone:303-440-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-09
Last Update Date:2021-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYTP248207R00000X
390200000X
CODR.0066949207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYTP248OtherLICENSE