Healthcare Provider Details

I. General information

NPI: 1427384684
Provider Name (Legal Business Name): JAY ALLEN LONGINO CRNFA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/22/2009
Last Update Date: 10/22/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 MEDI PARK DR BLDG D SUITE 2051
AMARILLO TX
79106-2110
US

IV. Provider business mailing address

1901 MEDI PARK DR BLDG D SUITE 2051
AMARILLO TX
79106-2110
US

V. Phone/Fax

Practice location:
  • Phone: 806-359-0718
  • Fax: 806-359-9613
Mailing address:
  • Phone: 806-359-0718
  • Fax: 806-359-9613

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZS0410X
TaxonomySurgical Technologist
License Number577874
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: