Basic Information
Provider Information | |||||||||
NPI: | 1467957860 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LONG | ||||||||
FirstName: | SARAH | ||||||||
MiddleName: | ROSE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | AGACNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | LOGAN | ||||||||
OtherFirstName: | SARAH | ||||||||
OtherMiddleName: | ROSE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 2101 N WALDRON ST | ||||||||
Address2: |   | ||||||||
City: | HUTCHINSON | ||||||||
State: | KS | ||||||||
PostalCode: | 675021197 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6206692500 | ||||||||
FaxNumber: | 6206942062 | ||||||||
Practice Location | |||||||||
Address1: | 2101 N WALDRON ST | ||||||||
Address2: |   | ||||||||
City: | HUTCHINSON | ||||||||
State: | KS | ||||||||
PostalCode: | 675021197 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6206944194 | ||||||||
FaxNumber: | 6206942128 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/27/2018 | ||||||||
LastUpdateDate: | 08/23/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/23/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | 53-78102-102 | KS | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363LA2100X | 53-78102-102 | KS | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care | 363L00000X | 5378102 | KS | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   |
No ID Information.