Healthcare Provider Details

I. General information

NPI: 1033587860
Provider Name (Legal Business Name): ANDREW LONG APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/10/2015
Last Update Date: 11/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

609 W MAPLE AVE
SPRINGDALE AR
72764-5335
US

IV. Provider business mailing address

609 W MAPLE AVE
SPRINGDALE AR
72764-5335
US

V. Phone/Fax

Practice location:
  • Phone: 479-751-5711
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberA004560
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2015032213
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: