Provider Demographics
NPI:1376208710
Name:DAVIS, STEPHANIE DENISE (PA)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:DENISE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 WINDGATE
Mailing Address - Street 2:
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92692-5173
Mailing Address - Country:US
Mailing Address - Phone:949-614-6181
Mailing Address - Fax:
Practice Address - Street 1:16405 SAND CANYON AVE STE 210
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92618-3786
Practice Address - Country:US
Practice Address - Phone:949-398-0106
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-01
Last Update Date:2021-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty