Provider Demographics
NPI:1265864730
Name:DAVIS, NICOLE L (PA-C)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:L
Last Name:DAVIS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:85 SEYMOUR ST
Mailing Address - Street 2:SUITE 709
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06106-5501
Mailing Address - Country:US
Mailing Address - Phone:860-696-2290
Mailing Address - Fax:860-696-2280
Practice Address - Street 1:85 SEYMOUR ST
Practice Address - Street 2:SUITE 709
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06106-5501
Practice Address - Country:US
Practice Address - Phone:860-696-2290
Practice Address - Fax:860-696-2280
Is Sole Proprietor?:No
Enumeration Date:2013-08-06
Last Update Date:2017-02-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CT003411363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical