Healthcare Provider Details

I. General information

NPI: 1023652633
Provider Name (Legal Business Name): AMY LONGFELLOW PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/06/2019
Last Update Date: 10/02/2026
Certification Date: 10/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1333 PASEO DEL PUEBLO SUR
TAOS NM
87571-5972
US

IV. Provider business mailing address

1333 PASEO DEL PUEBLO SUR
TAOS NM
87571-5972
US

V. Phone/Fax

Practice location:
  • Phone: 575-224-6320
  • Fax: 575-224-6320
Mailing address:
  • Phone: 575-224-6320
  • Fax: 575-224-6320

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberNMPA2019-0101
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberPA2019-0101
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: