Provider Demographics
NPI:1710934641
Name:LONG, TANIKA REONTAE (MD)
Entity Type:Individual
Prefix:DR
First Name:TANIKA
Middle Name:REONTAE
Last Name:LONG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:TANIKA
Other - Middle Name:REONTAE
Other - Last Name:MATHIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:30 MEDICAL CENTER BLVD
Mailing Address - Street 2:SUITE 305
Mailing Address - City:UPLAND
Mailing Address - State:PA
Mailing Address - Zip Code:19013-3955
Mailing Address - Country:US
Mailing Address - Phone:610-874-6448
Mailing Address - Fax:610-876-7399
Practice Address - Street 1:30 MEDICAL CENTER BLVD
Practice Address - Street 2:SUITE 305
Practice Address - City:UPLAND
Practice Address - State:PA
Practice Address - Zip Code:19013-3955
Practice Address - Country:US
Practice Address - Phone:610-874-6448
Practice Address - Fax:610-876-7399
Is Sole Proprietor?:No
Enumeration Date:2006-05-27
Last Update Date:2023-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA70297207L00000X
PAMD428458207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA428458OtherMD LICENSE