License Verification

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TRAVIS DAVID LONG

License Number: PA9107114

Data As Of 12/23/2024

Profession
Physician Assistant
License
PA9107114
License Status
CLEAR/Active
Qualifications
Prescribing
License Expiration Date
1/31/2026
License Original Issue Date
02/18/2013
Address of Record
350 N CLYDE MORRIS BLVD
FHCP Cardiology
DAYTONA BEACH, FL 32114
Controlled Substance Prescriber (for the Treatment of Chronic Non-malignant Pain)
No
Discipline on File
No
Public Complaint
No
Address
1630 Mason Ave JESUS CLINIC
DAYTONA BEACH, FL 32117
Name Relationship Profession License Effective Date
ESTRELLA, THENDREX HERNANDEZ Supervising Prescribing Practitioner Medical Doctor 113005 06/14/2017
MINOR, STEPHEN ERIC Supervising Prescribing Practitioner Medical Doctor 103969 01/09/2018
SMITH, RYAN ALAN Supervising Prescribing Practitioner Osteopathic Physician 15035 03/15/2018
WILSON, NILOUFAR Supervising Prescribing Practitioner Medical Doctor 143954 08/04/2020

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Name Relationship Profession License Effective Date

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Name Relationship Profession License Effective Date

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No Continuing Education Hours Received from Approved Providers As Of 12/23/2024



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** Personal Development is limited to no more than 3 hours per renewal cycle. Any personal development hours in excess of this 3 hour maximum cannot be used for renewal and have been subtracted from the total available for renewal.


Please do not fax proof of Continuing Education hours to the Board Office until you have received your renewal notice in the mail.


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