Provider Demographics
NPI:1063077303
Name:LONGO, JOANNA MARIE KLOSEK
Entity type:Individual
Prefix:
First Name:JOANNA
Middle Name:MARIE KLOSEK
Last Name:LONGO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JOANNA
Other - Middle Name:MARIE
Other - Last Name:LONGO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:424 MONTEMAR AVE
Mailing Address - Street 2:
Mailing Address - City:CATONSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21228-5213
Mailing Address - Country:US
Mailing Address - Phone:443-690-5894
Mailing Address - Fax:
Practice Address - Street 1:424 MONTEMAR AVE
Practice Address - Street 2:
Practice Address - City:CATONSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21228-5213
Practice Address - Country:US
Practice Address - Phone:443-690-5894
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-02
Last Update Date:2024-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant