Provider Demographics
NPI:1780758102
Name:LONGENECKER, ROBERT W (CRNA)
Entity type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:W
Last Name:LONGENECKER
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 1:2756 POINT REYES WAY
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95826-2471
Mailing Address - Country:US
Mailing Address - Phone:916-362-4093
Mailing Address - Fax:
Practice Address - Street 1:2025 MORSE AVE
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95825-2115
Practice Address - Country:US
Practice Address - Phone:916-973-7696
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA467367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered