Provider Demographics
NPI:1801406954
Name:LONGACRE, NATHANAEL JAMES
Entity Type:Individual
Prefix:
First Name:NATHANAEL
Middle Name:JAMES
Last Name:LONGACRE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2129
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79760-2129
Mailing Address - Country:US
Mailing Address - Phone:432-640-2408
Mailing Address - Fax:432-640-4606
Practice Address - Street 1:519 N LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79761-4429
Practice Address - Country:US
Practice Address - Phone:432-640-6446
Practice Address - Fax:432-640-6493
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-04
Last Update Date:2021-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA14987363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty