Provider Demographics
NPI:1699249615
Name:LONG, KENDRA RAY (PA-C)
Entity type:Individual
Prefix:MRS
First Name:KENDRA
Middle Name:RAY
Last Name:LONG
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KENDRA
Other - Middle Name:RAY
Other - Last Name:HALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4823 S LABURNUM AVE STE A
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23231-2713
Mailing Address - Country:US
Mailing Address - Phone:804-564-5852
Mailing Address - Fax:
Practice Address - Street 1:4823 S LABURNUM AVE STE A
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23231-2713
Practice Address - Country:US
Practice Address - Phone:804-564-5852
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-12
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110007047363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant