Healthcare Provider Details

I. General information

NPI: 1255548491
Provider Name (Legal Business Name): DANIEL WAYNE VANSKYHAWK II IDC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

414 CONCORD RD
PORTSMOUTH VA
23701-2231
US

IV. Provider business mailing address

414 CONCORD RD
PORTSMOUTH VA
23701-2231
US

V. Phone/Fax

Practice location:
  • Phone: 757-537-3813
  • Fax:
Mailing address:
  • Phone: 757-537-3813
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1003X
TaxonomyIndependent Duty Medical Technicians
License Number17101003X
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: