Provider Demographics
NPI:1427769892
Name:LONG, EDWARD
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:
Last Name:LONG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6825 S 7TH ST UNIT 91312
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85042-5440
Mailing Address - Country:US
Mailing Address - Phone:310-467-8223
Mailing Address - Fax:
Practice Address - Street 1:6825 S 7TH ST UNIT 91312
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85042-5440
Practice Address - Country:US
Practice Address - Phone:310-467-8223
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-07
Last Update Date:2022-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ282365174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ884316598Medicaid