Healthcare Provider Details

I. General information

NPI: 1639443104
Provider Name (Legal Business Name): KATHARINE CHRISTINA LONG M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/01/2012
Last Update Date: 07/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9300 VALLEY CHILDRENS PL VALLEY CHILDREN'S HOSPITAL
MADERA CA
93636-8761
US

IV. Provider business mailing address

1830 N SANDERS AVE
CLOVIS CA
93619-2010
US

V. Phone/Fax

Practice location:
  • Phone: 717-586-0629
  • Fax:
Mailing address:
  • Phone: 717-586-0629
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA119576
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License NumberMD452181
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: