Healthcare Provider Details

I. General information

NPI: 1710438528
Provider Name (Legal Business Name): DEANNA LONG PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/17/2016
Last Update Date: 08/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3850 GRANT AVE STE 200
LOVELAND CO
80538-8431
US

IV. Provider business mailing address

2695 ROCKY MOUNTAIN AVE STE 150
LOVELAND CO
80538-9071
US

V. Phone/Fax

Practice location:
  • Phone: 970-624-5170
  • Fax: 970-669-7521
Mailing address:
  • Phone: 970-624-2404
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA.0004822
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: