Provider Demographics
NPI:1124165626
Name:LONG, JAMES ELDON SR (PA-C)
Entity type:Individual
Prefix:MR
First Name:JAMES
Middle Name:ELDON
Last Name:LONG
Suffix:SR
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300A N,W, 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:WILLISTON
Mailing Address - State:FL
Mailing Address - Zip Code:32696-6262
Mailing Address - Country:US
Mailing Address - Phone:352-529-0966
Mailing Address - Fax:352-529-0967
Practice Address - Street 1:300A NW 1ST AVE
Practice Address - Street 2:
Practice Address - City:WILLISTON
Practice Address - State:FL
Practice Address - Zip Code:32696-2006
Practice Address - Country:US
Practice Address - Phone:352-529-0966
Practice Address - Fax:352-529-0967
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2014-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA2538363AM0700X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY09KUOtherBCBS
FL004428900Medicaid
FL004428900Medicaid
FLY09KUOtherBCBS
FL374619400Medicaid
FL004428900Medicaid