Provider Demographics
NPI:1649753013
Name:MCDERMOTT, DANIEL GUNNAR (RN, BSN)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:GUNNAR
Last Name:MCDERMOTT
Suffix:
Gender:M
Credentials:RN, BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:604 FORT WORTH AVE APT 2139
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75208-0259
Mailing Address - Country:US
Mailing Address - Phone:774-571-7867
Mailing Address - Fax:
Practice Address - Street 1:604 FORT WORTH AVE APT 2139
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75208-0259
Practice Address - Country:US
Practice Address - Phone:774-571-7867
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-12
Last Update Date:2018-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2325702163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse