Healthcare Provider Details

I. General information

NPI: 1417482167
Provider Name (Legal Business Name): CHARLES WYATT LONG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2017
Last Update Date: 07/17/2025
Certification Date: 07/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

212 THOMPSON ST STE C
HENDERSONVILLE NC
28792-2895
US

IV. Provider business mailing address

212 THOMPSON ST STE C
HENDERSONVILLE NC
28792-2895
US

V. Phone/Fax

Practice location:
  • Phone: 704-576-3356
  • Fax:
Mailing address:
  • Phone: 704-576-3356
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number100276
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code207XS0114X
TaxonomyAdult Reconstructive Orthopaedic Surgery Physician
License Number2025-01701
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: