Basic Information
| Provider Information | |||||||||
| NPI: | 1235771775 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HARBISON | ||||||||
| FirstName: | DANIEL | ||||||||
| MiddleName: | LINO | ||||||||
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| Credential: | ACNPC-AG | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4502 MEDICAL DR | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782294402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2103584000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4502 MEDICAL DR | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782294402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2103584000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/16/2019 | ||||||||
| LastUpdateDate: | 09/02/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | 0024178546 | VA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care | 363LA2100X | AP143575 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
ID Information
| ID | Type | State | Issuer | Description | 1235771775 | 01 | TX | CSHCN | OTHER | 1235771775 | 05 | TX | MEDICAID |