Basic Information
| Provider Information | |||||||||
| NPI: | 1437115284 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROLAND | ||||||||
| FirstName: | DANIEL | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | P.A.01 | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1975 W 24TH ST | ||||||||
| Address2: | |||||||||
| City: | YUMA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853646105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9283419522 | ||||||||
| FaxNumber: | 9283418492 | ||||||||
| Practice Location | |||||||||
| Address1: | 1975 W 24TH ST | ||||||||
| Address2: | |||||||||
| City: | YUMA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853646105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9283419522 | ||||||||
| FaxNumber: | 9283418492 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/21/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | X | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 1131 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | MR0697118 | 01 | AZ | DEA | OTHER |