Provider Demographics
NPI:1679152516
Name:MCDANIEL, DAVID LEWIS JR
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:LEWIS
Last Name:MCDANIEL
Suffix:JR
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 1:5545 MURRAY AVE STE 130
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38119-3861
Mailing Address - Country:US
Mailing Address - Phone:901-682-6828
Mailing Address - Fax:
Practice Address - Street 1:5545 MURRAY AVE STE 130
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-3861
Practice Address - Country:US
Practice Address - Phone:901-682-6828
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-07
Last Update Date:2021-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN29999367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered