Provider Demographics
NPI:1740226414
Name:SELLERS, DANIEL P (PA-C)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:P
Last Name:SELLERS
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 1:3340 E GOLDSTONE WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-1026
Mailing Address - Country:US
Mailing Address - Phone:208-377-0777
Mailing Address - Fax:208-367-1070
Practice Address - Street 1:6500 W EMERALD STREET
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704
Practice Address - Country:US
Practice Address - Phone:208-377-0777
Practice Address - Fax:208-367-1070
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA01055363A00000X, 363AS0400X
IDPA-1158363AS0400X, 363A00000X
WAPA10004868363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8433377Medicaid
OR500623570Medicaid
ORR163962Medicare PIN
ORR163702Medicare PIN
ORR158567Medicare PIN
Q50047Medicare UPIN
WA8855061Medicare ID - Type Unspecified
OR500623570Medicaid