Provider Demographics
NPI:1982989646
Name:LONGNECKER, PHILLIP (PA-C)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:
Last Name:LONGNECKER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1918 W FRONT ST
Mailing Address - Street 2:
Mailing Address - City:BERWICK
Mailing Address - State:PA
Mailing Address - Zip Code:18603-4230
Mailing Address - Country:US
Mailing Address - Phone:570-912-8144
Mailing Address - Fax:570-759-5494
Practice Address - Street 1:1918 W FRONT ST
Practice Address - Street 2:
Practice Address - City:BERWICK
Practice Address - State:PA
Practice Address - Zip Code:18603-4230
Practice Address - Country:US
Practice Address - Phone:570-912-8144
Practice Address - Fax:570-759-5494
Is Sole Proprietor?:No
Enumeration Date:2011-10-13
Last Update Date:2020-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA055226363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical