Provider Demographics
NPI:1255480018
Name:DAVIDSON, MICHAEL (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
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 1:1776 POLK ST APT 1917
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33020-4776
Mailing Address - Country:US
Mailing Address - Phone:210-819-9648
Mailing Address - Fax:
Practice Address - Street 1:1585 3RD ST
Practice Address - Street 2:
Practice Address - City:FORT POLK
Practice Address - State:LA
Practice Address - Zip Code:71459-5102
Practice Address - Country:US
Practice Address - Phone:337-531-3517
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2021-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041591363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical