Provider Demographics
NPI:1104224997
Name:DELLWO, DANIEL (PA-C)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:
Last Name:DELLWO
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 1:901 RANCHO LN STE 135
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89106-3826
Mailing Address - Country:US
Mailing Address - Phone:541-250-1525
Mailing Address - Fax:
Practice Address - Street 1:901 RANCHO LN STE 135
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89106-3826
Practice Address - Country:US
Practice Address - Phone:541-250-1525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-11
Last Update Date:2014-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-1192363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical