Healthcare Provider Details

I. General information

NPI: 1619659539
Provider Name (Legal Business Name): SKYLAR LONG PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2023
Last Update Date: 04/18/2025
Certification Date: 04/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12414 EXPOSITION BLVD
LOS ANGELES CA
90064-1016
US

IV. Provider business mailing address

12414 EXPOSITION BLVD
LOS ANGELES CA
90064-1016
US

V. Phone/Fax

Practice location:
  • Phone: 310-228-6400
  • Fax: 310-272-7656
Mailing address:
  • Phone: 310-228-6400
  • Fax: 310-272-7656

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number62967
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License NumberPA62967
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: