Healthcare Provider Details

I. General information

NPI: 1063166460
Provider Name (Legal Business Name): DANIEL JACOB SURBER PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/05/2022
Last Update Date: 02/05/2022
Certification Date: 02/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2315 NC HIGHWAY 242 N
BENSON NC
27504-7820
US

IV. Provider business mailing address

2918 LAKE JAMES DR
FUQUAY VARINA NC
27526-3919
US

V. Phone/Fax

Practice location:
  • Phone: 919-207-1717
  • Fax:
Mailing address:
  • Phone: 919-762-2129
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberA4767
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: