Basic Information
| Provider Information | |||||||||
| NPI: | 1114395597 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DANIELSON | ||||||||
| FirstName: | STACY | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2257 | ||||||||
| Address2: | |||||||||
| City: | CHESTERTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463040357 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2199268320 | ||||||||
| FaxNumber: | 2199263524 | ||||||||
| Practice Location | |||||||||
| Address1: | 1818 W FULTON ST STE 102 | ||||||||
| Address2: | |||||||||
| City: | RAPID CITY | ||||||||
| State: | SD | ||||||||
| PostalCode: | 577024347 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6057871040 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/02/2015 | ||||||||
| LastUpdateDate: | 09/02/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 0996 | SD | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.