Provider Demographics
NPI:1366520686
Name:LONG, RANDY J (PA-C, FAPACUS)
Entity type:Individual
Prefix:
First Name:RANDY
Middle Name:J
Last Name:LONG
Suffix:
Gender:M
Credentials:PA-C, FAPACUS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9350 E. 35TH STREET NORTH
Mailing Address - Street 2:SUITE 104
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67226
Mailing Address - Country:US
Mailing Address - Phone:316-616-6272
Mailing Address - Fax:316-616-0407
Practice Address - Street 1:9350 E. 35TH STREET NORTH
Practice Address - Street 2:SUITE 104
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67226
Practice Address - Country:US
Practice Address - Phone:316-616-6272
Practice Address - Fax:316-858-7085
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2010-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1500793363A00000X
KS15-00793363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100402610BMedicaid
KS2004260304Medicaid
KS426953OtherBLUE CROSS BLUE SHIELD
KSP38774Medicare UPIN
KS426953OtherBLUE CROSS BLUE SHIELD
KS426953Medicare ID - Type Unspecified
KS2004260304Medicaid