Provider Demographics
NPI:1073586186
Name:DAVIS, MARK A (PA-C)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:A
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 1:2611 FOREST DR STE 200
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29204-2371
Mailing Address - Country:US
Mailing Address - Phone:803-779-3263
Mailing Address - Fax:803-779-3207
Practice Address - Street 1:2611 FOREST DR STE 200
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29204-2371
Practice Address - Country:US
Practice Address - Phone:803-779-3263
Practice Address - Fax:803-779-3207
Is Sole Proprietor?:No
Enumeration Date:2006-02-09
Last Update Date:2018-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCPA2841363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
006773J05Medicare ID - Type Unspecified
Q37749Medicare UPIN