Provider Demographics
NPI:1588067276
Name:LONGINO, MEREDITH (PA-C)
Entity type:Individual
Prefix:
First Name:MEREDITH
Middle Name:
Last Name:LONGINO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MEREDITH
Other - Middle Name:
Other - Last Name:MURPHREE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1317 N HILLCREST
Mailing Address - Street 2:
Mailing Address - City:SULPHUR SPRINGS
Mailing Address - State:TX
Mailing Address - Zip Code:75482
Mailing Address - Country:US
Mailing Address - Phone:903-438-1110
Mailing Address - Fax:903-438-1107
Practice Address - Street 1:2401 S 31ST ST
Practice Address - Street 2:
Practice Address - City:TEMPLE
Practice Address - State:TX
Practice Address - Zip Code:76508-0001
Practice Address - Country:US
Practice Address - Phone:254-724-2111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-08
Last Update Date:2017-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX771280363L00000X, 363LP2300X
TXAP126569363LP2300X, 363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX126669402Medicaid