Provider Demographics
NPI:1093798282
Name:LIST, DARYL W (DO)
Entity Type:Individual
Prefix:
First Name:DARYL
Middle Name:W
Last Name:LIST
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1088
Mailing Address - Street 2:
Mailing Address - City:HERMITAGE
Mailing Address - State:PA
Mailing Address - Zip Code:16148-0088
Mailing Address - Country:US
Mailing Address - Phone:706-660-8505
Mailing Address - Fax:706-660-9390
Practice Address - Street 1:239 EDGEWOOD DR
Practice Address - Street 2:
Practice Address - City:TRANSFER
Practice Address - State:PA
Practice Address - Zip Code:16154-1817
Practice Address - Country:US
Practice Address - Phone:724-646-0400
Practice Address - Fax:724-646-0413
Is Sole Proprietor?:No
Enumeration Date:2005-11-22
Last Update Date:2012-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS003985L207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA000856690 0009Medicaid
PA101208491 0001Medicaid
B36654Medicare UPIN
PA105848S4DMedicare PIN