Provider Demographics
NPI:1780102970
Name:CONVERSE, MERCEDES LONGTON (PA-C)
Entity type:Individual
Prefix:
First Name:MERCEDES
Middle Name:LONGTON
Last Name:CONVERSE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MERCEDES
Other - Middle Name:SIMONE
Other - Last Name:LONGTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1640B SLEATER KINNEY RD NE
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98506-3730
Mailing Address - Country:US
Mailing Address - Phone:503-847-0141
Mailing Address - Fax:
Practice Address - Street 1:914 S SCHEUBER RD
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:WA
Practice Address - Zip Code:98531-9027
Practice Address - Country:US
Practice Address - Phone:503-847-0141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-07
Last Update Date:2019-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant