Provider Demographics
NPI:1942234521
Name:PERSON, DAN R (PA)
Entity Type:Individual
Prefix:
First Name:DAN
Middle Name:R
Last Name:PERSON
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 1:800 5TH AVE STE 500
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-7304
Mailing Address - Country:US
Mailing Address - Phone:817-878-5300
Mailing Address - Fax:817-878-5321
Practice Address - Street 1:800 5TH AVE STE 500
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-7304
Practice Address - Country:US
Practice Address - Phone:817-878-5300
Practice Address - Fax:817-878-5321
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2013-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA02133363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXS51545Medicare UPIN
TX8L9285Medicare PIN