Provider Demographics
NPI:1245748045
Name:KIRKLEY, DANIEL TERRELL (MMS PA-C)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:TERRELL
Last Name:KIRKLEY
Suffix:
Gender:M
Credentials:MMS PA-C
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 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7804 FAIRVIEW RD STE A
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28226-4999
Practice Address - Country:US
Practice Address - Phone:704-316-3136
Practice Address - Fax:704-316-3140
Is Sole Proprietor?:No
Enumeration Date:2018-01-15
Last Update Date:2024-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCMPA.2910207Q00000X, 2086S0127X
NC0010-08907363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC3620PAMedicaid