Provider Demographics
NPI:1851343396
Name:LONG, STAFFORD R (PA-C)
Entity Type:Individual
Prefix:
First Name:STAFFORD
Middle Name:R
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 1:2751 ALBERT L BICKNELL DR
Mailing Address - Street 2:SUITE 1-B
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71103-3920
Mailing Address - Country:US
Mailing Address - Phone:318-212-8776
Mailing Address - Fax:318-212-8774
Practice Address - Street 1:2751 ALBERT L BICKNELL DR
Practice Address - Street 2:SUITE 1-B
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-3920
Practice Address - Country:US
Practice Address - Phone:318-212-8776
Practice Address - Fax:318-212-8774
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2021-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPA.A10311363A00000X
LAPA A10311363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1722928Medicaid