Provider Demographics
NPI:1548680812
Name:LONG, DANIEL
Entity type:Individual
Prefix:
First Name:DANIEL
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 1:34 AGIN WAY
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:KY
Mailing Address - Zip Code:40045-1509
Mailing Address - Country:US
Mailing Address - Phone:859-979-2459
Mailing Address - Fax:
Practice Address - Street 1:1373 E STATE ROAD 62
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:IN
Practice Address - Zip Code:47250-7328
Practice Address - Country:US
Practice Address - Phone:317-783-7474
Practice Address - Fax:317-783-2283
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-24
Last Update Date:2014-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71004907A363LF0000X, 363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care