Provider Demographics
NPI:1477858801
Name:DAN NURSE PRACTITIONER SERVICES, LLC
Entity Type:Organization
Organization Name:DAN NURSE PRACTITIONER SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRINCIPAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:NICHOLS
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:928-595-1176
Mailing Address - Street 1:200 W. FRONTIER
Mailing Address - Street 2:SUITE M
Mailing Address - City:PAYSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85541-7443
Mailing Address - Country:US
Mailing Address - Phone:928-595-1176
Mailing Address - Fax:928-478-6206
Practice Address - Street 1:200 W FRONTIER ST
Practice Address - Street 2:SUITE M
Practice Address - City:PAYSON
Practice Address - State:AZ
Practice Address - Zip Code:85541-5362
Practice Address - Country:US
Practice Address - Phone:928-595-1176
Practice Address - Fax:928-478-6206
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-15
Last Update Date:2014-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP1489261QP2300X, 310400000X, 314000000X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Multi-Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ70871OtherMEDICARE ID NUMBER
P62785Medicare UPIN