Basic Information
| Provider Information | |||||||||
| NPI: | 1336169077 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LONG | ||||||||
| FirstName: | CHRISTIAN | ||||||||
| MiddleName: | DANIEL | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2196 E WILLIAMS FIELD RD | ||||||||
| Address2: | #116 | ||||||||
| City: | GILBERT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852950754 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4802371395 | ||||||||
| FaxNumber: | 6022184076 | ||||||||
| Practice Location | |||||||||
| Address1: | 2196 E WILLIAMS FIELD RD | ||||||||
| Address2: | #116 | ||||||||
| City: | GILBERT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852950754 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4802371395 | ||||||||
| FaxNumber: | 6022184076 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2006 | ||||||||
| LastUpdateDate: | 04/26/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 2642 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.