Provider Demographics
NPI:1407159288
Name:DAVIS, CAMILLA LEE (PA)
Entity Type:Individual
Prefix:
First Name:CAMILLA
Middle Name:LEE
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:PO BOX 405
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN CENTER
Mailing Address - State:CA
Mailing Address - Zip Code:92561-0450
Mailing Address - Country:US
Mailing Address - Phone:951-659-0534
Mailing Address - Fax:
Practice Address - Street 1:36921 COOK ST
Practice Address - Street 2:SUITE 102
Practice Address - City:PALM DESERT
Practice Address - State:CA
Practice Address - Zip Code:92211-6070
Practice Address - Country:US
Practice Address - Phone:760-836-9066
Practice Address - Fax:760-836-9077
Is Sole Proprietor?:No
Enumeration Date:2010-12-16
Last Update Date:2011-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA-21338363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical