Provider Demographics
NPI:1659144954
Name:BLACK, DANIEL
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:
Last Name:BLACK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14342 TILDEN ST
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:CA
Mailing Address - Zip Code:92683-5139
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1851 MELANIE CT
Practice Address - Street 2:
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93454-5505
Practice Address - Country:US
Practice Address - Phone:805-325-0042
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-30
Last Update Date:2024-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA64104363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant