Provider Demographics
NPI:1285172106
Name:LOLLATHIN, DANIEL CODY (PA-C)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:CODY
Last Name:LOLLATHIN
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 1:11 LAKEVIEW CT
Mailing Address - Street 2:
Mailing Address - City:BIDWELL
Mailing Address - State:OH
Mailing Address - Zip Code:45614-9004
Mailing Address - Country:US
Mailing Address - Phone:740-612-9094
Mailing Address - Fax:
Practice Address - Street 1:515 UNION AVE
Practice Address - Street 2:SUITE 167
Practice Address - City:DOVER
Practice Address - State:OH
Practice Address - Zip Code:44622-3004
Practice Address - Country:US
Practice Address - Phone:330-343-3335
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-11
Last Update Date:2017-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.004991RX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant