=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407646839
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DALTON SHEVLIN
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/08/2025
-----------------------------------------------------
Last Update Date | 12/20/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 905 CALLE AMANECER STE 115
-----------------------------------------------------
City | SAN CLEMENTE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92673-6226
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 194-920-7360
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1631 DOHENY WAY
-----------------------------------------------------
City | DANA POINT
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92629-5926
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 513-462-1687
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------