Provider Demographics
NPI:1992535330
Name:CEBALLOS, DANIEL T (AGNP)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:T
Last Name:CEBALLOS
Suffix:
Gender:M
Credentials:AGNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 410770
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-0770
Mailing Address - Country:US
Mailing Address - Phone:314-851-1000
Mailing Address - Fax:
Practice Address - Street 1:12655 OLIVE BLVD FL 4
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-6291
Practice Address - Country:US
Practice Address - Phone:314-394-7444
Practice Address - Fax:314-627-8957
Is Sole Proprietor?:No
Enumeration Date:2024-08-01
Last Update Date:2024-08-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO2024026725363LG0600X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology