1972873198 NPI number — DANIEL S VISSER PA-C

Table of content: DANIEL S VISSER PA-C (NPI 1972873198)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972873198 NPI number — DANIEL S VISSER PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VISSER
Provider First Name:
DANIEL
Provider Middle Name:
S
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1972873198
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/09/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2650 N TENAYA WAY
Provider Second Line Business Mailing Address:
301
Provider Business Mailing Address City Name:
LAS VEGAS
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89128-1102
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
702-258-5521
Provider Business Mailing Address Fax Number:
702-938-0137

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2650 N TENAYA WAY # 301
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAS VEGAS
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89128-1102
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
702-258-5521
Provider Business Practice Location Address Fax Number:
702-938-0137
Provider Enumeration Date:
01/04/2012

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  PA 1323 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: FU392Y . This is a "MEDICARE PTAN" identifier , issued by the state of ( NV ) . This identifiers is of the category "OTHER".
  • Identifier: PA 1323 . This is a "PA LICENSE" identifier , issued by the state of ( NV ) . This identifiers is of the category "OTHER".