Provider Demographics
NPI:1376797795
Name:POLLACK, DANIELL BENNETT (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:DANIELL
Middle Name:BENNETT
Last Name:POLLACK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:DANIELL
Other - Middle Name:MARGARET
Other - Last Name:BENNETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4065 3RD AVENUE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-2184
Mailing Address - Country:US
Mailing Address - Phone:619-542-0013
Mailing Address - Fax:619-542-0559
Practice Address - Street 1:4065 3RD AVENUE
Practice Address - Street 2:SUITE 102
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-2184
Practice Address - Country:US
Practice Address - Phone:619-542-0013
Practice Address - Fax:619-542-0559
Is Sole Proprietor?:No
Enumeration Date:2008-11-12
Last Update Date:2010-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA20005363AM0700X
CAPA2005363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACL606YMedicare PIN