Healthcare Provider Details

I. General information

NPI: 1194041590
Provider Name (Legal Business Name): JANE A LONGEST PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JANE A KIRWAN

II. Dates (important events)

Enumeration Date: 04/12/2010
Last Update Date: 06/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9715 HEALTHWAY DR
BERLIN MD
21811
US

IV. Provider business mailing address

PO BOX 3177
SALISBURY MD
21802-3177
US

V. Phone/Fax

Practice location:
  • Phone: 410-548-2343
  • Fax: 844-332-3891
Mailing address:
  • Phone: 410-548-2343
  • Fax: 844-332-3891

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC5-0000817
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: