1124165626 NPI number — MR. JAMES ELDON LONG SR. PA-C

Table of content: MR. JAMES ELDON LONG SR. PA-C (NPI 1124165626)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124165626 NPI number — MR. JAMES ELDON LONG SR. PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LONG
Provider First Name:
JAMES
Provider Middle Name:
ELDON
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
SR.
Provider Credential Text:
PA-C
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1124165626
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/29/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
300A N,W, 1ST AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WILLISTON
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32696-6262
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
352-529-0966
Provider Business Mailing Address Fax Number:
352-529-0967

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
300A NW 1ST AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WILLISTON
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32696-2006
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
352-529-0966
Provider Business Practice Location Address Fax Number:
352-529-0967
Provider Enumeration Date:
01/31/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363AM0700X , with the licence number:  PA2538 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: Y09KU . This is a "BCBS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 004428900 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".