Provider Demographics
NPI:1033325741
Name:DAVIS, GREGORY C (PA)
Entity Type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:C
Last Name:DAVIS
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Gender:M
Credentials:PA
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Mailing Address - Street 1:14050 NW 14TH ST
Mailing Address - Street 2:SUITE 190
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33323-2865
Mailing Address - Country:US
Mailing Address - Phone:800-424-3672
Mailing Address - Fax:954-377-3042
Practice Address - Street 1:303 PARKWAY DR NE
Practice Address - Street 2:ER DEPT
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30312-1212
Practice Address - Country:US
Practice Address - Phone:404-265-4136
Practice Address - Fax:404-265-3903
Is Sole Proprietor?:No
Enumeration Date:2007-05-16
Last Update Date:2007-07-08
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Provider Licenses
StateLicense IDTaxonomies
GA004622363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAPENDINGMedicare UPIN