Provider Demographics
NPI:1205091535
Name:LONGUSKI, KEITH LEONARD (PA-C, ATC)
Entity type:Individual
Prefix:MR
First Name:KEITH
Middle Name:LEONARD
Last Name:LONGUSKI
Suffix:
Gender:M
Credentials:PA-C, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3945 N UBLY RD
Mailing Address - Street 2:
Mailing Address - City:UBLY
Mailing Address - State:MI
Mailing Address - Zip Code:48475-9764
Mailing Address - Country:US
Mailing Address - Phone:816-812-0013
Mailing Address - Fax:
Practice Address - Street 1:1 LOWER NAVY HILL ROAD
Practice Address - Street 2:
Practice Address - City:NAVY HILL
Practice Address - State:SAIPAN
Practice Address - Zip Code:96950
Practice Address - Country:UM
Practice Address - Phone:670-234-8950
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-25
Last Update Date:2013-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS24-006112255A2300X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS22OtherRESPIRATORY, REHABILITATIVE & RESTORATIVE SERVICE PROVIDER