Basic Information
Provider Information
NPI: 1043239775
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: LONG
FirstName: MICHAEL
MiddleName: ARLIN
NamePrefix:  
NameSuffix:  
Credential: P.A.-C.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 450 4TH ST.
Address2: PO BOX 367
City: DASSEL
State: MN
PostalCode: 55325
CountryCode: US
TelephoneNumber: 3202753358
FaxNumber:  
Practice Location
Address1: 450 4TH ST.
Address2:  
City: DASSEL
State: MN
PostalCode: 55325
CountryCode: US
TelephoneNumber: 3202753358
FaxNumber:  
Other Information
ProviderEnumerationDate: 07/19/2006
LastUpdateDate: 07/08/2007
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
363A00000X9836MNY Physician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant 

ID Information
IDTypeStateIssuerDescription
89148770005MN MEDICAID


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