Provider Demographics
NPI:1770672701
Name:FORSBERG, DANIEL GLENN (PA-C)
Entity Type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:GLENN
Last Name:FORSBERG
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 1:1345 RXR PLZ
Mailing Address - Street 2:
Mailing Address - City:UNIONDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11556-1301
Mailing Address - Country:US
Mailing Address - Phone:516-453-0435
Mailing Address - Fax:
Practice Address - Street 1:1044 NORTHERN BLVD
Practice Address - Street 2:SUITE 302
Practice Address - City:ROSLYN
Practice Address - State:NY
Practice Address - Zip Code:11576-1514
Practice Address - Country:US
Practice Address - Phone:516-621-1313
Practice Address - Fax:516-621-0116
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2019-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003030363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical