Basic Information
| Provider Information | |||||||||
| NPI: | 1134121445 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DANIELS | ||||||||
| FirstName: | DANIEL | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 30731 | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336303731 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004768646 | ||||||||
| FaxNumber: | 9193823210 | ||||||||
| Practice Location | |||||||||
| Address1: | 110 LONGWOOD AVE | ||||||||
| Address2: | |||||||||
| City: | ROCKLEDGE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329552828 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004768646 | ||||||||
| FaxNumber: | 9193823210 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2005 | ||||||||
| LastUpdateDate: | 08/04/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA9102480 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 258402600 | 05 | FL | MEDICAID |