Provider Demographics
NPI:1801825195
Name:EUSTACE, DANIEL L (PA-C)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:L
Last Name:EUSTACE
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 1:311 W I ST
Mailing Address - Street 2:
Mailing Address - City:LOS BANOS
Mailing Address - State:CA
Mailing Address - Zip Code:93635-3479
Mailing Address - Country:US
Mailing Address - Phone:209-826-2222
Mailing Address - Fax:
Practice Address - Street 1:311 W I ST
Practice Address - Street 2:
Practice Address - City:LOS BANOS
Practice Address - State:CA
Practice Address - Zip Code:93635
Practice Address - Country:US
Practice Address - Phone:209-826-2222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-01
Last Update Date:2020-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC02993363A00000X
CA54524363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDKR38K733Medicare ID - Type Unspecified
MDQ38874Medicare UPIN