Healthcare Provider Details

I. General information

NPI: 1104262781
Provider Name (Legal Business Name): TRAVIS DAVID LONG PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2013
Last Update Date: 05/12/2026
Certification Date: 05/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2565 ENTERPRISE RD STE 400
ORANGE CITY FL
32763-8016
US

IV. Provider business mailing address

2565 ENTERPRISE RD STE 400
ORANGE CITY FL
32763-8016
US

V. Phone/Fax

Practice location:
  • Phone: 321-841-6444
  • Fax: 321-842-1955
Mailing address:
  • Phone: 321-841-6444
  • Fax: 321-842-1955

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9107114
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA9107114
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: