Healthcare Provider Details

I. General information

NPI: 1134146137
Provider Name (Legal Business Name): KAREN W LONG MMS-PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KAREN M WIEDEMAN MMS-PA-C

II. Dates (important events)

Enumeration Date: 07/16/2006
Last Update Date: 07/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2750 CLAY EDWARDS DR SUITE 410
NORTH KANSAS CITY MO
64116-3237
US

IV. Provider business mailing address

2750 CLAY EDWARDS DR SUITE 410
NORTH KANSAS CITY MO
64116-3237
US

V. Phone/Fax

Practice location:
  • Phone: 816-471-8114
  • Fax: 816-842-5342
Mailing address:
  • Phone: 816-471-8114
  • Fax: 816-842-5342

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberOPA180510
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA18051
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA18051
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: