Healthcare Provider Details

I. General information

NPI: 1356047542
Provider Name (Legal Business Name): DANIEL KONCHAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2023
Last Update Date: 07/21/2026
Certification Date: 07/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

219 MARGUERITE AVE
CORONA DEL MAR CA
92625-3043
US

IV. Provider business mailing address

219 MARGUERITE AVE
CORONA DEL MAR CA
92625-3043
US

V. Phone/Fax

Practice location:
  • Phone: 949-209-1563
  • Fax: 949-539-8822
Mailing address:
  • Phone: 949-209-1563
  • Fax: 949-539-8822

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA62239
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: