Provider Demographics
NPI:1104179183
Name:DAVIDSON, AMY NOBLE (PA-C)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:NOBLE
Last Name:DAVIDSON
Suffix:
Gender:F
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 1:1450 COLUMBUS AVE STE B 6-7-8
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON COURT HOUSE
Mailing Address - State:OH
Mailing Address - Zip Code:43160-3701
Mailing Address - Country:US
Mailing Address - Phone:740-333-2236
Mailing Address - Fax:740-333-3881
Practice Address - Street 1:1450 COLUMBUS AVE STE 103
Practice Address - Street 2:
Practice Address - City:WASHINGTON COURT HOUSE
Practice Address - State:OH
Practice Address - Zip Code:43160-3701
Practice Address - Country:US
Practice Address - Phone:740-333-2243
Practice Address - Fax:740-333-2248
Is Sole Proprietor?:No
Enumeration Date:2012-10-16
Last Update Date:2020-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0077380Medicaid
OHH157750Medicare PIN