MEDICARE: MARIANNE LONG PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AS0400X	Surgical Physician Assistant	PA371	KY

General Provider Information

NPI Number	:	1770555609
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARIANNE LONG PA-C

Provider Business Mailing Address
First Line	:	PO BOX 8500
Second Line	:	LOCKBOX 7642
City	:	PHILADELPHIA
State	:	PA
Zip	:	19178-7642
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1900 RICHMOND RD
Second Line	:
City	:	LEXINGTON
State	:	KY
Zip	:	40502-1204
Country	:	US
Telephone Number	:	859-266-2101
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/04/2006
Last Update Date	:	11/16/2012

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Directions to “ MARIANNE LONG PA-C” Practice Location

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