Provider Demographics
NPI:1023049046
Name:VICTOR D LONG CRNA MS INC
Entity type:Organization
Organization Name:VICTOR D LONG CRNA MS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:VICTOR
Authorized Official - Middle Name:D
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA MS
Authorized Official - Phone:405-364-6182
Mailing Address - Street 1:415 W GRAY ST
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73069-7117
Mailing Address - Country:US
Mailing Address - Phone:405-364-6182
Mailing Address - Fax:405-364-5379
Practice Address - Street 1:415 W GRAY ST
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73069-7117
Practice Address - Country:US
Practice Address - Phone:405-364-6182
Practice Address - Fax:405-364-5379
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-06
Last Update Date:2008-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0033797367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100785020BMedicaid
OK430067242OtherRR MEDICARE PIN
OK100785020BMedicaid
OK100785020BMedicaid