Provider Demographics
NPI:1679596134
Name:ORTIZ, DANIEL R (PA-C)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:R
Last Name:ORTIZ
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 1:1394 W 16TH ST
Mailing Address - Street 2:
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85364-4430
Mailing Address - Country:US
Mailing Address - Phone:928-539-0055
Mailing Address - Fax:928-539-0053
Practice Address - Street 1:1394 W 16TH ST
Practice Address - Street 2:
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85364-4430
Practice Address - Country:US
Practice Address - Phone:928-539-0055
Practice Address - Fax:928-539-0053
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2012-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2043363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZP54729Medicare UPIN
AZZ102893Medicare ID - Type Unspecified