Provider Demographics
NPI:1114023595
Name:DAVISON, TROY ALLEN
Entity Type:Individual
Prefix:
First Name:TROY
Middle Name:ALLEN
Last Name:DAVISON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3931 STOCKTON HILL RD
Mailing Address - Street 2:STE C
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86409-3001
Mailing Address - Country:US
Mailing Address - Phone:928-681-6100
Mailing Address - Fax:
Practice Address - Street 1:3931 STOCKTON HILL RD
Practice Address - Street 2:STE C
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86409-3001
Practice Address - Country:US
Practice Address - Phone:928-681-6100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-15
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2978363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ940206Medicaid
AZMD1044508OtherDEA
AZ940206Medicaid