Provider Demographics
NPI:1992759740
Name:LONG, KEVIN R (ARNP)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:R
Last Name:LONG
Suffix:
Gender:M
Credentials:ARNP
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:4205 BELFORT RD STE 4015
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-3623
Mailing Address - Country:US
Mailing Address - Phone:904-296-5691
Mailing Address - Fax:904-450-6401
Practice Address - Street 1:1824 KING ST STE 300
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204
Practice Address - Country:US
Practice Address - Phone:904-388-1820
Practice Address - Fax:904-388-1827
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2018-08-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLARNP2869582363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL012160200Medicaid
FLU4903WMedicare PIN