Basic Information
| Provider Information | |||||||||
| NPI: | 1568759298 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LONG | ||||||||
| FirstName: | KRISTEN | ||||||||
| MiddleName: | L. | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GROSS | ||||||||
| OtherFirstName: | KRISTEN | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 10401 SPOTSTSYLVANIA AVE | ||||||||
| Address2: | STE 200 | ||||||||
| City: | FREDERICKSBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 224082691 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5403611000 | ||||||||
| FaxNumber: | 5403617010 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 MEDICAL CENTER BLVD | ||||||||
| Address2: | |||||||||
| City: | CHESTER | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190133902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6105214833 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/01/2011 | ||||||||
| LastUpdateDate: | 05/24/2019 | ||||||||
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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 | MA054968 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | MA054968 | 01 | PA | PA LICENSE | OTHER |