Healthcare Provider Details

I. General information

NPI: 1568166130
Provider Name (Legal Business Name): GRIFFIN LONGLEY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2023
Last Update Date: 08/12/2024
Certification Date: 08/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

940 RIVER CENTRE DR
PORT HURON MI
48060-4463
US

IV. Provider business mailing address

6672 NEWARK RD
IMLAY CITY MI
48444-9657
US

V. Phone/Fax

Practice location:
  • Phone: 810-985-4900
  • Fax: 810-985-3634
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601011643
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: