Basic Information
| Provider Information | |||||||||
| NPI: | 1346743911 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LONG | ||||||||
| FirstName: | KATHLEEN | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1822 S LOGAN ST | ||||||||
| Address2: | |||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802103126 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7203185325 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2468, 75 NIELSON ST | ||||||||
| Address2: | |||||||||
| City: | WATSONVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95076 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8317244741 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2018 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 55261 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.