Healthcare Provider Details

I. General information

NPI: 1689157331
Provider Name (Legal Business Name): GEDEON LONGTCHI FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/10/2018
Last Update Date: 06/01/2022
Certification Date: 06/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2454 VINEYARD LN
CROFTON MD
21114-1116
US

IV. Provider business mailing address

2454 VINEYARD LN
CROFTON MD
21114-1116
US

V. Phone/Fax

Practice location:
  • Phone: 240-353-2357
  • Fax:
Mailing address:
  • Phone: 240-353-2357
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN1026502
License Number StateDC
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR199900
License Number StateMD
# 3
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberR162583
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: