Healthcare Provider Details

I. General information

NPI: 1760711162
Provider Name (Legal Business Name): CHRISTOPHER WAYNE DANIELS PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/14/2009
Last Update Date: 12/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23 MEDICAL GROUP 3278 MITCHELL BLVD
MOODY A F B GA
31699-0001
US

IV. Provider business mailing address

3278 MITCHELL BLVD 23 MEDICAL GROUP
MOODY AFB GA
31699
US

V. Phone/Fax

Practice location:
  • Phone: 229-257-1459
  • Fax: 229-257-5520
Mailing address:
  • Phone: 229-257-1459
  • Fax: 229-257-5520

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: