Provider Demographics
NPI:1770533317
Name:LONG, ALLAN LOUIS (CRNA)
Entity type:Individual
Prefix:
First Name:ALLAN
Middle Name:LOUIS
Last Name:LONG
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2505 ALLEN ADALE RD
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99709-2581
Mailing Address - Country:US
Mailing Address - Phone:301-300-2077
Mailing Address - Fax:
Practice Address - Street 1:1060 GAFFNEY RD STOP 7400
Practice Address - Street 2:
Practice Address - City:FORT WAINWRIGHT
Practice Address - State:AK
Practice Address - Zip Code:99703-5007
Practice Address - Country:US
Practice Address - Phone:907-361-5532
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-12
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK116420367500000X
PARN521826L367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered