Provider Demographics
NPI:1174294938
Name:DAVIDSON, DOUGLAS PETER JR (PA)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:PETER
Last Name:DAVIDSON
Suffix:JR
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38332 MAPLE CT
Mailing Address - Street 2:
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92562-3406
Mailing Address - Country:US
Mailing Address - Phone:951-816-8970
Mailing Address - Fax:
Practice Address - Street 1:50 ACACIA AVE
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-2230
Practice Address - Country:US
Practice Address - Phone:951-816-8970
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-22
Last Update Date:2023-03-07
Deactivation Date:2022-02-26
Deactivation Code:
Reactivation Date:2022-12-05
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA62399363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program