Basic Information
| Provider Information | |||||||||
| NPI: | 1811643554 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LONG | ||||||||
| FirstName: | CONNOR | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 CALUMET ST APT 2 | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021203651 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4025808970 | ||||||||
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| Practice Location | |||||||||
| Address1: | 55 FOGG RD | ||||||||
| Address2: | |||||||||
| City: | SOUTH WEYMOUTH | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021902455 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7816248000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/22/2022 | ||||||||
| LastUpdateDate: | 02/22/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/22/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.