Provider Demographics
NPI:1720678170
Name:LONGNECKER, DYLAN MICHAEL (DNAP, CRNA)
Entity Type:Individual
Prefix:
First Name:DYLAN
Middle Name:MICHAEL
Last Name:LONGNECKER
Suffix:
Gender:M
Credentials:DNAP, CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9520 COTTESMORE LN
Mailing Address - Street 2:
Mailing Address - City:HENRICO
Mailing Address - State:VA
Mailing Address - Zip Code:23228-2042
Mailing Address - Country:US
Mailing Address - Phone:434-422-2791
Mailing Address - Fax:
Practice Address - Street 1:1250 E MARSHALL ST
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23298-5023
Practice Address - Country:US
Practice Address - Phone:804-628-4748
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-20
Last Update Date:2021-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024180810367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered