Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LA2100X | Nurse Practitioner - Acute Care | 2016006780 | MO |
NPI | 1003276866 |
---|---|
Provider Name | Doug Longo |
First Address | Saint Louis, MO 63110-2520 |
Second Address | Saint Louis, MO 63104-1016 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 07/03/2016 |
Last Update Date | 30/10/2020 |