Provider Demographics
NPI:1770764136
Name:RICK, DANIEL B (PA)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:B
Last Name:RICK
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:PO BOX 12358
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30914-2358
Mailing Address - Country:US
Mailing Address - Phone:706-863-9595
Mailing Address - Fax:706-447-7184
Practice Address - Street 1:3100 CHANNING WAY
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7533
Practice Address - Country:US
Practice Address - Phone:706-863-9595
Practice Address - Fax:706-447-7184
Is Sole Proprietor?:No
Enumeration Date:2007-11-14
Last Update Date:2022-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK138794363A00000X
IDPA-1246363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant