Provider Demographics
NPI:1184361214
Name:LONG, NICHOLAS GEORGE (RN)
Entity type:Individual
Prefix:MR
First Name:NICHOLAS
Middle Name:GEORGE
Last Name:LONG
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2191 MARION ST
Mailing Address - Street 2:
Mailing Address - City:NORTH BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97459-2314
Mailing Address - Country:US
Mailing Address - Phone:541-756-8022
Mailing Address - Fax:
Practice Address - Street 1:2191 MARION ST
Practice Address - Street 2:
Practice Address - City:NORTH BEND
Practice Address - State:OR
Practice Address - Zip Code:97459-2314
Practice Address - Country:US
Practice Address - Phone:541-756-8022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-19
Last Update Date:2022-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR092003400RN163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse