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General NPI Number Information
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NPI Number | 1982605911
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Entity Type | Individual
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Provider Name | MR. KENNETH D LONG
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Gender | Male
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Dates
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Enumeration Date | 08/01/2005
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 1251 NE ELM ST
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City | PRINEVILLE
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State | OR
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Zip | 97754
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Country | US
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Telephone | 541-447-1680
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Fax | 541-447-4670
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Provider Business Mailing Address
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Address Line | 1251 NE ELM ST
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City | PRINEVILLE
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State | OR
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Zip | 97754
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Country | US
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Telephone | 541-447-1680
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Fax | 541-447-4670
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | PA00535
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License Number State | OR
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