Provider Demographics
NPI:1326577578
Name:BEJARANO PUENTES, DANIEL EDUARDO (CNP)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:EDUARDO
Last Name:BEJARANO PUENTES
Suffix:
Gender:M
Credentials:CNP
Other - Prefix:
Other - First Name:DANIEL
Other - Middle Name:E
Other - Last Name:BEJARANO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RN
Mailing Address - Street 1:3712 RUNYON AVE
Mailing Address - Street 2:
Mailing Address - City:TROTWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:45416-1341
Mailing Address - Country:US
Mailing Address - Phone:937-278-5155
Mailing Address - Fax:
Practice Address - Street 1:823 MICHIGAN ST
Practice Address - Street 2:
Practice Address - City:SIDNEY
Practice Address - State:OH
Practice Address - Zip Code:45365-2685
Practice Address - Country:US
Practice Address - Phone:937-498-5334
Practice Address - Fax:937-494-5914
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-09
Last Update Date:2020-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.020979363L00000X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0234227Medicaid