Provider Demographics
NPI:1245815737
Name:LONG, MADELEINE GINETTE (PA-C)
Entity type:Individual
Prefix:
First Name:MADELEINE
Middle Name:GINETTE
Last Name:LONG
Suffix:
Gender:F
Credentials:PA-C
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Mailing Address - Street 1:416 ABBY DR
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25314-2423
Mailing Address - Country:US
Mailing Address - Phone:304-993-4470
Mailing Address - Fax:
Practice Address - Street 1:2300 MACCORKLE AVE SE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25304-1045
Practice Address - Country:US
Practice Address - Phone:800-995-4682
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-16
Last Update Date:2021-03-16
Deactivation Date:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant