Basic Information
| Provider Information | |||||||||
| NPI: | 1821312174 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | DANIEL | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 401 S BALLENGER HWY | ||||||||
| Address2: | |||||||||
| City: | FLINT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 485323638 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8103421000 | ||||||||
| FaxNumber: | 8103421590 | ||||||||
| Practice Location | |||||||||
| Address1: | 6465 MILLENNIUM | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 489176880 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5179753720 | ||||||||
| FaxNumber: | 5179753748 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/16/2010 | ||||||||
| LastUpdateDate: | 03/16/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 5601004846 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.