Healthcare Provider Details

I. General information

NPI: 1851343396
Provider Name (Legal Business Name): STAFFORD R LONG PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2006
Last Update Date: 06/03/2021
Certification Date: 06/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2751 ALBERT L BICKNELL DR SUITE 1-B
SHREVEPORT LA
71103-3920
US

IV. Provider business mailing address

2751 ALBERT L BICKNELL DR SUITE 1-B
SHREVEPORT LA
71103-3920
US

V. Phone/Fax

Practice location:
  • Phone: 318-212-8776
  • Fax: 318-212-8774
Mailing address:
  • Phone: 318-212-8776
  • Fax: 318-212-8774

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA.A10311
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA A10311
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: