Healthcare Provider Details

I. General information

NPI: 1033108626
Provider Name (Legal Business Name): DANIEL JOSEPH KOMRO PHYSICIAN ASSISTANT
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/17/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4700 LAS VEGAS BLVD N
NELLIS AFB NV
89191-6600
US

IV. Provider business mailing address

6453 CHATTERER ST
NORTH LAS VEGAS NV
89084-2820
US

V. Phone/Fax

Practice location:
  • Phone: 702-653-3971
  • Fax: 702-653-3622
Mailing address:
  • Phone: 702-839-0166
  • Fax: 702-653-3622

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: