Provider Demographics
NPI:1578704623
Name:WELBURN, DANIEL E (PA-C)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:E
Last Name:WELBURN
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 1:833 W WHITTIER BLVD
Mailing Address - Street 2:
Mailing Address - City:MONTEBELLO
Mailing Address - State:CA
Mailing Address - Zip Code:90640-4735
Mailing Address - Country:US
Mailing Address - Phone:323-712-4811
Mailing Address - Fax:323-544-6488
Practice Address - Street 1:833 W WHITTIER BLVD
Practice Address - Street 2:
Practice Address - City:MONTEBELLO
Practice Address - State:CA
Practice Address - Zip Code:90640-4735
Practice Address - Country:US
Practice Address - Phone:323-712-4811
Practice Address - Fax:323-544-6488
Is Sole Proprietor?:No
Enumeration Date:2009-03-19
Last Update Date:2019-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA20234207Q00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA20234OtherCA LICENSE - PHYSICIAN ASSISTANT
CARN527054OtherCA LICENSE - REGISTERED NURSE