Healthcare Provider Details

I. General information

NPI: 1750356465
Provider Name (Legal Business Name): DANIEL J KVALE PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2006
Last Update Date: 01/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 W MAIN ST
BISON SD
57620-0003
US

IV. Provider business mailing address

PO BOX 427
BISON SD
57620-0427
US

V. Phone/Fax

Practice location:
  • Phone: 605-244-5206
  • Fax: 605-244-5208
Mailing address:
  • Phone: 605-244-5206
  • Fax: 605-244-5208

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0549
License Number StateSD

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier5350300
Identifier TypeMEDICAID
Identifier StateSD
Identifier Issuer
# 2
Identifier42507
Identifier TypeOTHER
Identifier StateSD
Identifier IssuerMED B

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: