Provider Demographics
NPI:1629512645
Name:LONG, NICHOLAS (PA-C)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:LONG
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3600 W BETHEL AVE
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47304-5407
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6301 HARRIS PKWY STE 300
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76132-4266
Practice Address - Country:US
Practice Address - Phone:817-877-3432
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-09
Last Update Date:2025-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10002175A363A00000X
TXPA19181363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant