Healthcare Provider Details

I. General information

NPI: 1851663017
Provider Name (Legal Business Name): CALINE DAUN LONG PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/03/2012
Last Update Date: 04/11/2024
Certification Date: 04/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5000 MEMORIAL DR
TWO RIVERS WI
54241
US

IV. Provider business mailing address

1035 KEPLER DR
GREEN BAY WI
54311-8320
US

V. Phone/Fax

Practice location:
  • Phone: 920-794-5125
  • Fax: 920-794-5465
Mailing address:
  • Phone: 920-490-9046
  • Fax: 920-405-5388

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-03270
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number4310
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: