Provider Demographics
NPI:1124286877
Name:LONG, ANGELA M (CRNA)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:M
Last Name:LONG
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:ANGELA
Other - Middle Name:M
Other - Last Name:BASE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:PO BOX 22390
Mailing Address - Street 2:
Mailing Address - City:HOT SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:71903-2390
Mailing Address - Country:US
Mailing Address - Phone:800-235-1415
Mailing Address - Fax:913-234-1108
Practice Address - Street 1:1910 MALVERN AVE
Practice Address - Street 2:
Practice Address - City:HOT SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:71901-7752
Practice Address - Country:US
Practice Address - Phone:800-235-1415
Practice Address - Fax:913-234-1108
Is Sole Proprietor?:No
Enumeration Date:2008-05-29
Last Update Date:2009-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR73939163W00000X
ARCTP000068367500000X
ARCO2708367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR174706001Medicaid
ARP00628608OtherRR MEDICARE GROUP CG8899
AR1124286877OtherBCBS OF AR
AR1124286877OtherBCBS OF AR
AR174706001Medicaid