Healthcare Provider Details

I. General information

NPI: 1679562664
Provider Name (Legal Business Name): DEBRA SUE LONGBINE RPA C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/21/2005
Last Update Date: 04/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6970 ERIE RD
DERBY NY
14047-9591
US

IV. Provider business mailing address

6970 ERIE RD
DERBY NY
14047-9591
US

V. Phone/Fax

Practice location:
  • Phone: 716-947-9147
  • Fax: 716-947-5175
Mailing address:
  • Phone: 716-947-9147
  • Fax: 716-947-5175

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number001449
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: