Provider Demographics
NPI:1720040652
Name:LONG, LARRY (PA-C)
Entity Type:Individual
Prefix:MR
First Name:LARRY
Middle Name:
Last Name:LONG
Suffix:
Gender:M
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 1:909 FROSTWOOD DR
Mailing Address - Street 2:SUITE 1.100
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77024-2301
Mailing Address - Country:US
Mailing Address - Phone:713-338-4523
Mailing Address - Fax:
Practice Address - Street 1:9305 PINECROFT DR
Practice Address - Street 2:SUITE 101
Practice Address - City:THE WOODLANDS
Practice Address - State:TX
Practice Address - Zip Code:77380-3482
Practice Address - Country:US
Practice Address - Phone:713-897-7500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2015-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA05436363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant