MEDICARE: MR. DANIEL JAMES BEQUILLARD PHYSICIAN ASSISTANT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1038252	OTHER		NCCPA NUMBER

General Provider Information

NPI Number	:	1154410041
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DANIEL JAMES BEQUILLARD PHYSICIAN ASSISTANT

Provider Business Mailing Address
First Line	:	PSC 450 BOX 412
Second Line	:
City	:	APO AP
State	:	CA
Zip	:	96206
Country	:	US
Telephone Number	:	817-217-9029
Fax Number	:

Provider Business Practice Location Address
First Line	:	600 CUT OFF RD STE 14
Second Line	:
City	:	PORT ARANSAS
State	:	TX
Zip	:	78373-4246
Country	:	US
Telephone Number	:	361-749-1930
Fax Number	:	361-749-1933

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/11/2006
Last Update Date	:	10/17/2024

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