Provider Demographics
NPI:1255434155
Name:OBRIEN, DANIEL T (PA)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:T
Last Name:OBRIEN
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 1:43350 TYLER RD
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48111-4330
Mailing Address - Country:US
Mailing Address - Phone:313-576-3724
Mailing Address - Fax:
Practice Address - Street 1:4646 JOHN R ST
Practice Address - Street 2:11M
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-1916
Practice Address - Country:US
Practice Address - Phone:313-576-3724
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601001300363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical