Provider Demographics
NPI:1366827982
Name:DAVIDSON, KEITH (NP-C)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:
Last Name:DAVIDSON
Suffix:
Gender:M
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 126
Mailing Address - Street 2:3532 MAIN STREET
Mailing Address - City:DECKERVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48427-0126
Mailing Address - Country:US
Mailing Address - Phone:810-376-3100
Mailing Address - Fax:810-376-8311
Practice Address - Street 1:2433 BLACK RIVER ST
Practice Address - Street 2:
Practice Address - City:DECKERVILLE
Practice Address - State:MI
Practice Address - Zip Code:48427-9425
Practice Address - Country:US
Practice Address - Phone:810-376-2885
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-24
Last Update Date:2022-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704274292363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health