Provider Demographics
NPI:1639825680
Name:MISSERI, DANIEL ROBERT (PTA)
Entity Type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:ROBERT
Last Name:MISSERI
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3421
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23439-3421
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1401 N HIGH ST
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:VA
Practice Address - Zip Code:23851-1244
Practice Address - Country:US
Practice Address - Phone:757-517-0743
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-28
Last Update Date:2022-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306605893225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant