Healthcare Provider Details

I. General information

NPI: 1427255769
Provider Name (Legal Business Name): DANIEL WILSON KREVDO RPA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 GRIFFIN AVE
EASTMAN GA
31023-6720
US

IV. Provider business mailing address

621 NORTH AVENUE, NE SUITE C-30
ATLANTA GA
30308
US

V. Phone/Fax

Practice location:
  • Phone: 478-448-4048
  • Fax: 478-374-9797
Mailing address:
  • Phone: 678-904-6820
  • Fax: 678-904-6824

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2471V0106X
TaxonomyVascular-Interventional Technology Radiologic Technologist
License NumberJX39313
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code2471C3401X
TaxonomyComputed Tomography Radiologic Technologist
License NumberJX39313
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code2471C3402X
TaxonomyRadiography Radiologic Technologist
License NumberJX39313
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: