Basic Information
| Provider Information | |||||||||
| NPI: | 1972128924 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DELONG | ||||||||
| FirstName: | JOSEPH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1423 PEGER RD | ||||||||
| Address2: | |||||||||
| City: | FAIRBANKS | ||||||||
| State: | AK | ||||||||
| PostalCode: | 997095169 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2067072555 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1423 PEGER RD | ||||||||
| Address2: | |||||||||
| City: | FAIRBANKS | ||||||||
| State: | AK | ||||||||
| PostalCode: | 997095169 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9073711300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2020 | ||||||||
| LastUpdateDate: | 02/22/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/22/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 363A00000X | 186204 | AK | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.