Provider Demographics
NPI:1912455387
Name:LONG, ANTHONY D JR (CSA)
Entity Type:Individual
Prefix:MR
First Name:ANTHONY
Middle Name:D
Last Name:LONG
Suffix:JR
Gender:M
Credentials:CSA
Other - Prefix:
Other - First Name:
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Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:17 MOCKINGBIRD LN
Mailing Address - Street 2:
Mailing Address - City:PINE BLUFF
Mailing Address - State:AR
Mailing Address - Zip Code:71603-6107
Mailing Address - Country:US
Mailing Address - Phone:870-556-0976
Mailing Address - Fax:
Practice Address - Street 1:17 MOCKINGBIRD LN
Practice Address - Street 2:
Practice Address - City:PINE BLUFF
Practice Address - State:AR
Practice Address - Zip Code:71603-6107
Practice Address - Country:US
Practice Address - Phone:870-556-0976
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-14
Last Update Date:2016-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR4651363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR81-3831260OtherEIN