Basic Information
| Provider Information | |||||||||
| NPI: | 1104262781 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LONG | ||||||||
| FirstName: | TRAVIS | ||||||||
| MiddleName: | DAVID | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 732901 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753732901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3862264590 | ||||||||
| FaxNumber: | 3862263371 | ||||||||
| Practice Location | |||||||||
| Address1: | 303 N CLYDE MORRIS BLVD | ||||||||
| Address2: | |||||||||
| City: | DAYTONA BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321142709 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3862544000 | ||||||||
| FaxNumber: | 3864257522 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2013 | ||||||||
| LastUpdateDate: | 03/03/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA9107114 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 0089009-00 | 05 | FL | MEDICAID | 003135044A | 05 | GA | MEDICAID | 008900900 | 05 | FL | MEDICAID | Y0HL0 | 01 | FL | BLUE CROSS BLUE SHIELD | OTHER |