Provider Demographics
NPI:1972873198
Name:VISSER, DANIEL S (PA-C)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:S
Last Name:VISSER
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 1:2650 N TENAYA WAY
Mailing Address - Street 2:301
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89128-1102
Mailing Address - Country:US
Mailing Address - Phone:702-258-5521
Mailing Address - Fax:702-938-0137
Practice Address - Street 1:2650 N TENAYA WAY # 301
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-1102
Practice Address - Country:US
Practice Address - Phone:702-258-5521
Practice Address - Fax:702-938-0137
Is Sole Proprietor?:No
Enumeration Date:2012-01-04
Last Update Date:2013-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPA 1323363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVFU392YOtherMEDICARE PTAN
NVPA 1323OtherPA LICENSE