Provider Demographics
NPI:1417914730
Name:DAVIS, PATRICK W (PAC)
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:W
Last Name:DAVIS
Suffix:
Gender:M
Credentials:PAC
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 752287
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89136-2287
Mailing Address - Country:US
Mailing Address - Phone:702-604-7422
Mailing Address - Fax:702-549-3178
Practice Address - Street 1:724 KENDALL LN
Practice Address - Street 2:
Practice Address - City:BOULDER CITY
Practice Address - State:NV
Practice Address - Zip Code:89005-1112
Practice Address - Country:US
Practice Address - Phone:702-604-7422
Practice Address - Fax:702-549-3178
Is Sole Proprietor?:No
Enumeration Date:2006-04-28
Last Update Date:2019-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPA823363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVPA823OtherNSBME
NV100502933Medicaid
AZ850273Medicaid
NVP00206370OtherRAILROAD MEDICARE
NVCC535YOtherMEDICARE PTAN
AZ850273Medicaid
NV100502933Medicaid