Provider Demographics
NPI:1962824086
Name:LONG, ANGELA GRACE (PA-C)
Entity Type:Individual
Prefix:MS
First Name:ANGELA
Middle Name:GRACE
Last Name:LONG
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ANGELA
Other - Middle Name:GRACE
Other - Last Name:SASAKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:DEPT. 453 PO BOX 1000
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38148-0001
Mailing Address - Country:US
Mailing Address - Phone:828-575-2625
Mailing Address - Fax:828-350-2174
Practice Address - Street 1:3201 N VAN BUREN ST STE 350
Practice Address - Street 2:
Practice Address - City:ENID
Practice Address - State:OK
Practice Address - Zip Code:73703-1814
Practice Address - Country:US
Practice Address - Phone:580-366-0844
Practice Address - Fax:580-297-5197
Is Sole Proprietor?:No
Enumeration Date:2014-01-08
Last Update Date:2023-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4519363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1O8717OtherMEDICARE PTAN
OK200984110AMedicaid