Provider Demographics
NPI:1982605911
Name:LONG, KENNETH D
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:D
Last Name:LONG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1251 NE ELM ST
Mailing Address - Street 2:
Mailing Address - City:PRINEVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97754
Mailing Address - Country:US
Mailing Address - Phone:541-447-1680
Mailing Address - Fax:541-447-4670
Practice Address - Street 1:1251 NE ELM ST
Practice Address - Street 2:
Practice Address - City:PRINEVILLE
Practice Address - State:OR
Practice Address - Zip Code:97754
Practice Address - Country:US
Practice Address - Phone:541-447-1680
Practice Address - Fax:541-447-4670
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA00535363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
13503OtherCLEAR CHOICE
93071013397754A001OtherTRICARE WEST
9700113590OtherRAILROAD MEDICARE
GRP331OtherPROVIDENCE HEALTH PLANS
H3079OtherPACIFIC SOURCE
13503OtherCOIHS
OR205625Medicaid
H3079OtherPACIFIC SOURCE
9700113590OtherRAILROAD MEDICARE