Provider Demographics
NPI:1942598347
Name:LONGAN, RANDY
Entity Type:Individual
Prefix:
First Name:RANDY
Middle Name:
Last Name:LONGAN
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 1:2300 N ELM ST UNIT A
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:OK
Mailing Address - Zip Code:74354-1524
Mailing Address - Country:US
Mailing Address - Phone:918-542-2845
Mailing Address - Fax:
Practice Address - Street 1:130 W STEVE OWENS BLVD
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:OK
Practice Address - Zip Code:74354-7629
Practice Address - Country:US
Practice Address - Phone:918-542-2845
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-19
Last Update Date:2011-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator