Provider Demographics
NPI:1336425560
Name:CARDWELL, DANIEL L (PA-C)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:L
Last Name:CARDWELL
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 1:12251 S 80TH AVE STE 1520
Mailing Address - Street 2:
Mailing Address - City:PALOS HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60463-1290
Mailing Address - Country:US
Mailing Address - Phone:708-923-4200
Mailing Address - Fax:708-923-4201
Practice Address - Street 1:12251 S 80TH AVE STE 1520
Practice Address - Street 2:
Practice Address - City:PALOS HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60463-1290
Practice Address - Country:US
Practice Address - Phone:708-923-4200
Practice Address - Fax:708-923-4201
Is Sole Proprietor?:No
Enumeration Date:2011-11-02
Last Update Date:2024-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110004653363AS0400X
IL085004797363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1336425560Medicaid
VA1336425560OtherNPI