Provider Demographics
NPI:1295478824
Name:MCDANIEL, CONNOR M
Entity type:Individual
Prefix:
First Name:CONNOR
Middle Name:M
Last Name:MCDANIEL
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:CAS
Other - Middle Name:M
Other - Last Name:MCDANIEL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:460 N MAGNOLIA AVE STE 110
Mailing Address - Street 2:
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92020-3610
Mailing Address - Country:US
Mailing Address - Phone:619-440-5133
Mailing Address - Fax:619-440-8522
Practice Address - Street 1:460 N MAGNOLIA AVE STE 110
Practice Address - Street 2:
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92020-3610
Practice Address - Country:US
Practice Address - Phone:619-440-5133
Practice Address - Fax:619-440-8522
Is Sole Proprietor?:No
Enumeration Date:2022-04-20
Last Update Date:2025-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program