Provider Demographics
NPI:1013580331
Name:DAVIDSON, BRYAN RICHARD (PA-C)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:RICHARD
Last Name:DAVIDSON
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 1:6502 ROYAL OAKLAND DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46236-4802
Mailing Address - Country:US
Mailing Address - Phone:317-513-7144
Mailing Address - Fax:
Practice Address - Street 1:110 E 13TH ST
Practice Address - Street 2:
Practice Address - City:RUSHVILLE
Practice Address - State:IN
Practice Address - Zip Code:46173-2126
Practice Address - Country:US
Practice Address - Phone:765-932-7063
Practice Address - Fax:765-932-7065
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-23
Last Update Date:2021-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10003308A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty