Provider Demographics
NPI:1083647960
Name:DAVIS, CLIFTON H (PA-C)
Entity Type:Individual
Prefix:
First Name:CLIFTON
Middle Name:H
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 1:3688 VETERANS MEMORIAL DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-8246
Mailing Address - Country:US
Mailing Address - Phone:601-554-7400
Mailing Address - Fax:601-554-7488
Practice Address - Street 1:3688 VETERANS MEMORIAL DR
Practice Address - Street 2:SUITE 200
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39401-8246
Practice Address - Country:US
Practice Address - Phone:601-554-7400
Practice Address - Fax:601-554-7488
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2009-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPA021363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01802226Medicaid
MS880000008Medicare ID - Type Unspecified
MS01802226Medicaid