Provider Demographics
NPI:1346210754
Name:MCKIM, DANIEL S (PA)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:S
Last Name:MCKIM
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1924 CHAMBERS CIR
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:94513-5922
Mailing Address - Country:US
Mailing Address - Phone:925-759-4987
Mailing Address - Fax:
Practice Address - Street 1:1700 N CHRISMAN RD
Practice Address - Street 2:
Practice Address - City:TRACY
Practice Address - State:CA
Practice Address - Zip Code:95304-9314
Practice Address - Country:US
Practice Address - Phone:925-759-4987
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-26
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1045485363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical