Provider Demographics
NPI:1013229806
Name:DAVIDSON, NICOLE RENEE (PA)
Entity Type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:RENEE
Last Name:DAVIDSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:DEPT 3038 PO BOX 4417
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77210-4417
Mailing Address - Country:US
Mailing Address - Phone:610-644-8900
Mailing Address - Fax:484-924-0053
Practice Address - Street 1:10238 E HAMPTON AVE STE 501
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85209-3321
Practice Address - Country:US
Practice Address - Phone:480-889-1573
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-08
Last Update Date:2022-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9106627363A00000X
NY014040363A00000X
AZ6037363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant