Provider Demographics
NPI:1356602460
Name:BALCERAK, DANIEL W (PA-C)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:W
Last Name:BALCERAK
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 1:2250 173RD ST
Mailing Address - Street 2:
Mailing Address - City:HAMMOND
Mailing Address - State:IN
Mailing Address - Zip Code:46323-2074
Mailing Address - Country:US
Mailing Address - Phone:765-494-0111
Mailing Address - Fax:877-451-0472
Practice Address - Street 1:2250 173RD ST
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:IN
Practice Address - Zip Code:46323-2074
Practice Address - Country:US
Practice Address - Phone:765-494-0111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-05
Last Update Date:2023-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10001437A363AS0400X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN0449980008Medicare NSC
IN473320001Medicare PIN
IN0449980013Medicare NSC
IN0449980001Medicare NSC
IN0449980009Medicare NSC