Provider Demographics
NPI:1073692463
Name:DAVIS, CHAD D (PA - C)
Entity Type:Individual
Prefix:MR
First Name:CHAD
Middle Name:D
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 1:500 8TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52401-2134
Mailing Address - Country:US
Mailing Address - Phone:319-364-8704
Mailing Address - Fax:319-365-7747
Practice Address - Street 1:500 8TH AVE SE
Practice Address - Street 2:
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52401-2134
Practice Address - Country:US
Practice Address - Phone:319-364-8704
Practice Address - Fax:319-365-7747
Is Sole Proprietor?:No
Enumeration Date:2006-11-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001524363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA35956OtherBLUE CROSS BLUE SHIELD
IAQ02516Medicare UPIN
IAI10822Medicare ID - Type Unspecified