Provider Demographics
NPI:1194725762
Name:GWAN-NULLA, DANIEL N (MD)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:N
Last Name:GWAN-NULLA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:707 CENTER ST STE 110
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31901-1575
Mailing Address - Country:US
Mailing Address - Phone:706-494-4300
Mailing Address - Fax:706-660-2847
Practice Address - Street 1:1831 5TH AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31904
Practice Address - Country:US
Practice Address - Phone:706-320-8780
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-26
Last Update Date:2018-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA208600000X174400000X
MO2009014868208600000X, 208G00000X
NC2009-01579208G00000X
GA080790208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
No174400000XOther Service ProvidersSpecialist
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1194725762Medicaid
PA1011329740001Medicaid
PA1626778OtherBLUE CROSS
MO1194725762Medicaid
PAI18346Medicare UPIN