Provider Demographics
NPI:1407312614
Name:DANIELSON, DAVID ALLEN
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:ALLEN
Last Name:DANIELSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 W 5TH ST
Mailing Address - Street 2:
Mailing Address - City:ZUMBROTA
Mailing Address - State:MN
Mailing Address - Zip Code:55992-1157
Mailing Address - Country:US
Mailing Address - Phone:507-884-1481
Mailing Address - Fax:507-732-7370
Practice Address - Street 1:615 W 5TH ST
Practice Address - Street 2:
Practice Address - City:ZUMBROTA
Practice Address - State:MN
Practice Address - Zip Code:55992-1157
Practice Address - Country:US
Practice Address - Phone:507-884-1481
Practice Address - Fax:507-732-7370
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-12
Last Update Date:2019-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN383010343900000X, 347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN383010OtherSTS #383010