Provider Demographics
NPI:1548488364
Name:DESPEN, DANIEL (PHYSICIAN ASST)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:
Last Name:DESPEN
Suffix:
Gender:M
Credentials:PHYSICIAN ASST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 GERARD AVE EAST
Mailing Address - Street 2:
Mailing Address - City:MALVERNE
Mailing Address - State:NY
Mailing Address - Zip Code:11565
Mailing Address - Country:US
Mailing Address - Phone:516-599-8380
Mailing Address - Fax:
Practice Address - Street 1:888 FOUNTAIN AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11208-5997
Practice Address - Country:US
Practice Address - Phone:718-642-6352
Practice Address - Fax:718-642-7890
Is Sole Proprietor?:No
Enumeration Date:2007-04-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001042363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Not Answered363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical