Individual
MR. KENNETH D LONG
Active
Sole proprietor
Provider details
NPI number
Gender
Man
Contact information
Practice address
1251 NE ELM ST, PRINEVILLE, OR 97754
(541) 447-1680
(541) 447-4670
Mailing address
1251 NE ELM ST, PRINEVILLE, OR 97754
(541) 447-1680
(541) 447-4670
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
PA00535
OR
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
13503
CLEAR CHOICE
—
05
—
205625
—
OR
01
—
93071013397754A001
TRICARE WEST
—
01
—
9700113590
RAILROAD MEDICARE
—
01
—
GRP331
PROVIDENCE HEALTH PLANS
—
01
—
H3079
PACIFIC SOURCE
—
Enumeration date
08/01/2005
Last updated
07/08/2007
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