Provider Demographics
NPI:1033288998
Name:DAVIS, GREGORY DAVID (PA-C)
Entity Type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:DAVID
Last Name:DAVIS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1628
Mailing Address - Street 2:
Mailing Address - City:LAKE ISABELLA
Mailing Address - State:CA
Mailing Address - Zip Code:93240-1628
Mailing Address - Country:US
Mailing Address - Phone:760-379-1791
Mailing Address - Fax:760-379-1793
Practice Address - Street 1:4300 BIRCH AVE
Practice Address - Street 2:
Practice Address - City:LAKE ISABELLA
Practice Address - State:CA
Practice Address - Zip Code:93240-1628
Practice Address - Country:US
Practice Address - Phone:760-379-1791
Practice Address - Fax:760-379-1793
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA 13448363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical