Provider Demographics
NPI:1477862696
Name:ACEVEDO, DANIEL JAMES (PA-C)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:JAMES
Last Name:ACEVEDO
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 1:2405 ATHERHOLT RD
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24501-2184
Mailing Address - Country:US
Mailing Address - Phone:434-485-8500
Mailing Address - Fax:434-485-8599
Practice Address - Street 1:14521 FOREST RD STE D
Practice Address - Street 2:
Practice Address - City:FOREST
Practice Address - State:VA
Practice Address - Zip Code:24551-4079
Practice Address - Country:US
Practice Address - Phone:434-485-8555
Practice Address - Fax:434-485-8594
Is Sole Proprietor?:No
Enumeration Date:2010-10-05
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110004479363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1477862696Medicaid
VA1477862696Medicaid
P01584721Medicare PIN