Provider Demographics
NPI:1912096306
Name:LONG, KEVIN R (LMP)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:R
Last Name:LONG
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:3217 EASTLAKE AVE E APT 304
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98102-7124
Mailing Address - Country:US
Mailing Address - Phone:253-224-0103
Mailing Address - Fax:
Practice Address - Street 1:4902 TACOMA MALL BLVD
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98409-7149
Practice Address - Country:US
Practice Address - Phone:253-473-0300
Practice Address - Fax:253-473-0305
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00016150174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist