Provider Demographics
NPI:1003540410
Name:DAVIS, MICHAEL KEVIN (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:KEVIN
Last Name:DAVIS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13 LAXFORD DR
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19702-4265
Mailing Address - Country:US
Mailing Address - Phone:302-358-1053
Mailing Address - Fax:
Practice Address - Street 1:316 LANTANA DR
Practice Address - Street 2:
Practice Address - City:HOCKESSIN
Practice Address - State:DE
Practice Address - Zip Code:19707-8807
Practice Address - Country:US
Practice Address - Phone:302-766-9700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-12
Last Update Date:2023-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC5-0011756363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty