Basic Information
| Provider Information | |||||||||
| NPI: | 1801406954 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LONGACRE | ||||||||
| FirstName: | NATHANAEL | ||||||||
| MiddleName: | JAMES | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2129 | ||||||||
| Address2: | |||||||||
| City: | ODESSA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 797602129 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4326402408 | ||||||||
| FaxNumber: | 4326404606 | ||||||||
| Practice Location | |||||||||
| Address1: | 519 N LINCOLN AVE | ||||||||
| Address2: | |||||||||
| City: | ODESSA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 797614429 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4326406446 | ||||||||
| FaxNumber: | 4326406493 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2020 | ||||||||
| LastUpdateDate: | 10/12/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA14987 | TX | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.