Provider Demographics
NPI:1467244970
Name:LONG, BRAXTON
Entity type:Individual
Prefix:
First Name:BRAXTON
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 1:4777 COUNTY ROAD 407
Mailing Address - Street 2:
Mailing Address - City:HANNIBAL
Mailing Address - State:MO
Mailing Address - Zip Code:63401-6509
Mailing Address - Country:US
Mailing Address - Phone:573-822-6475
Mailing Address - Fax:
Practice Address - Street 1:1411 S POTOMAC ST STE 350
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80012-4543
Practice Address - Country:US
Practice Address - Phone:720-324-9380
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-20
Last Update Date:2025-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPTL.0020583208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation