Provider Demographics
NPI:1710438528
Name:LONG, DEANNA (PA-C)
Entity Type:Individual
Prefix:
First Name:DEANNA
Middle Name:
Last Name:LONG
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2695 ROCKY MOUNTAIN AVE STE 150
Mailing Address - Street 2:
Mailing Address - City:LOVELAND
Mailing Address - State:CO
Mailing Address - Zip Code:80538-9071
Mailing Address - Country:US
Mailing Address - Phone:970-624-2404
Mailing Address - Fax:
Practice Address - Street 1:3850 GRANT AVE STE 200
Practice Address - Street 2:
Practice Address - City:LOVELAND
Practice Address - State:CO
Practice Address - Zip Code:80538-8431
Practice Address - Country:US
Practice Address - Phone:970-624-5170
Practice Address - Fax:970-669-7521
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-17
Last Update Date:2019-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0004822363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000142742Medicaid
CO9000142742Medicaid
COPA.0004822Medicare UPIN