Healthcare Provider Details

I. General information

NPI: 1578663779
Provider Name (Legal Business Name): BRIAN LONG
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 03/22/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2211 LOMAS BLVD NE 2ND FLOOR
ALBUQUERQUE NM
87106-2719
US

IV. Provider business mailing address

933 BRADBURY DR SE SUITE 2222
ALBUQUERQUE NM
87106-4374
US

V. Phone/Fax

Practice location:
  • Phone: 505-272-2336
  • Fax: 505-272-5103
Mailing address:
  • Phone: 505-272-1320
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number720372
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCNP-02380
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: