Provider Demographics
NPI:1508166646
Name:KELLEHER, DANIEL A (NP)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:A
Last Name:KELLEHER
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 BAKER ST
Mailing Address - Street 2:
Mailing Address - City:FOXBORO
Mailing Address - State:MA
Mailing Address - Zip Code:02035-1902
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:157 UNION ST
Practice Address - Street 2:DEPARTMENT OF EMERGENCY MEDICINE
Practice Address - City:MARLBOROUGH
Practice Address - State:MA
Practice Address - Zip Code:01752-1228
Practice Address - Country:US
Practice Address - Phone:508-421-1400
Practice Address - Fax:508-421-1490
Is Sole Proprietor?:No
Enumeration Date:2010-10-22
Last Update Date:2017-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN267406363LA2100X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110097151AMedicaid
MA002353302Medicare PIN
MAS400261388Medicare PIN
MA002353303Medicare PIN
MA002353301Medicare PIN
MA002353304Medicare PIN
MAS400261388Medicare Oscar/Certification
MA110097151AMedicaid