Healthcare Provider Details

I. General information

NPI: 1073160768
Provider Name (Legal Business Name): DANIEL EWING CRNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2019
Last Update Date: 03/01/2020
Certification Date: 03/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11301 WILSHIRE BLVD BLDG 402
LOS ANGELES CA
90073-1003
US

IV. Provider business mailing address

4054 SAWTELLE BLVD
LOS ANGELES CA
90066-5408
US

V. Phone/Fax

Practice location:
  • Phone: 310-478-3711
  • Fax:
Mailing address:
  • Phone: 740-975-2746
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number95202017
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95012999
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: