Provider Demographics
NPI:1760478085
Name:LANDES, DANIAL (PA)
Entity Type:Individual
Prefix:
First Name:DANIAL
Middle Name:
Last Name:LANDES
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7490 NEW TECHNOLOGY WAY
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21703
Mailing Address - Country:US
Mailing Address - Phone:301-870-7001
Mailing Address - Fax:301-870-6697
Practice Address - Street 1:7490 NEW TECHNOLOGY WAY
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21703
Practice Address - Country:US
Practice Address - Phone:301-870-7001
Practice Address - Fax:301-870-6697
Is Sole Proprietor?:No
Enumeration Date:2005-09-22
Last Update Date:2007-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0002454363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD014916S66Medicare ID - Type UnspecifiedINDIVIDUAL MEDICARE #