Provider Demographics
NPI:1235389412
Name:DAVIDSON, CORY BENNETT (PA-C)
Entity Type:Individual
Prefix:
First Name:CORY
Middle Name:BENNETT
Last Name:DAVIDSON
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 1:3822 COLONIAL AVE STE C
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16506-3826
Mailing Address - Country:US
Mailing Address - Phone:814-616-0321
Mailing Address - Fax:814-528-5643
Practice Address - Street 1:3822 COLONIAL AVE STE C
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16506-3826
Practice Address - Country:US
Practice Address - Phone:814-616-0321
Practice Address - Fax:814-528-5643
Is Sole Proprietor?:No
Enumeration Date:2008-09-24
Last Update Date:2024-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA053612363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAMA053612OtherLICENSE
PAMA053612OtherLICENSE