Provider Demographics
NPI:1801525472
Name:CABANERO, DANIEL ROQUE (PA-C)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:ROQUE
Last Name:CABANERO
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 1:2080 CENTURY PARK E STE 1407
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90067-2017
Mailing Address - Country:US
Mailing Address - Phone:310-277-2929
Mailing Address - Fax:310-277-2924
Practice Address - Street 1:12922 VICTORY BLVD
Practice Address - Street 2:
Practice Address - City:NORTH HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:91606-2924
Practice Address - Country:US
Practice Address - Phone:818-760-2800
Practice Address - Fax:818-760-7343
Is Sole Proprietor?:No
Enumeration Date:2022-06-08
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1197258363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant