Provider Demographics
NPI:1558021493
Name:REID, DANIEL JOHN (PA-C)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:JOHN
Last Name:REID
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 1:29150 LAKE FOREST BLVD APT 1911
Mailing Address - Street 2:
Mailing Address - City:DAPHNE
Mailing Address - State:AL
Mailing Address - Zip Code:36526-7597
Mailing Address - Country:US
Mailing Address - Phone:850-316-1640
Mailing Address - Fax:
Practice Address - Street 1:3900 WOODLAND AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-4551
Practice Address - Country:US
Practice Address - Phone:850-316-1640
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-20
Last Update Date:2021-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1869363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant