Provider Demographics
NPI:1992308811
Name:KIERNAN, DANIEL
Entity type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:
Last Name:KIERNAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3241 WESTERN BRANCH BLVD
Mailing Address - Street 2:STE A
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23321-5260
Mailing Address - Country:US
Mailing Address - Phone:757-686-3508
Mailing Address - Fax:757-686-0541
Practice Address - Street 1:1359 SIMON DR
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-7669
Practice Address - Country:US
Practice Address - Phone:757-615-1692
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-21
Last Update Date:2021-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA00110007985363A00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program