Basic Information
| Provider Information | |||||||||
| NPI: | 1831175777 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LONG | ||||||||
| FirstName: | NIKKI | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 960046 | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731960001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8774854474 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1600 HOSPITAL PKWY | ||||||||
| Address2: | |||||||||
| City: | BEDFORD | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760226913 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8176854000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/22/2005 | ||||||||
| LastUpdateDate: | 10/20/2010 | ||||||||
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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 | 207P00000X | L4538 | TX | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 158403901 | 05 | TX | MEDICAID | 8G7452 | 01 | TX | BCBS | OTHER | 158403906 | 05 | TX | MEDICAID | P00026012 | 01 | TX | MEDICARE RAILROAD | OTHER | 8F4449 | 01 | TX | BCBS | OTHER | P00052875 | 01 | TX | RAILROAD MCARE | OTHER | P00427826 | 01 | TX | RAILROAD THRU HEB | OTHER |