=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124165626
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JAMES ELDON LONG SR. PA-C
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/31/2007
-----------------------------------------------------
Last Update Date | 04/29/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 300A NW 1ST AVE
-----------------------------------------------------
City | WILLISTON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32696-2006
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-529-0966
-----------------------------------------------------
Fax | 352-529-0967
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 300A N,W, 1ST AVE
-----------------------------------------------------
City | WILLISTON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32696-6262
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-529-0966
-----------------------------------------------------
Fax | 352-529-0967
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | PA2538
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------