Provider Demographics
NPI:1407982366
Name:TELLER, DANIEL PAUL (PA-C)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:PAUL
Last Name:TELLER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1995 E OAKLAND PARK BLVD STE 310
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33306-1138
Mailing Address - Country:US
Mailing Address - Phone:954-791-6146
Mailing Address - Fax:954-337-2733
Practice Address - Street 1:1995 E OAKLAND PARK BLVD STE 310
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33306-1138
Practice Address - Country:US
Practice Address - Phone:954-791-6146
Practice Address - Fax:954-337-2733
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2020-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601001590363AM0700X
FLPA9109236363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0G36084P05Medicare ID - Type Unspecified
MIR68706Medicare UPIN