Provider Demographics
NPI:1417959453
Name:DAVIDSON, NANCY ALICE (MD)
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:ALICE
Last Name:DAVIDSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6800 PALM AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:SEBASTOPOL
Mailing Address - State:CA
Mailing Address - Zip Code:95472-4269
Mailing Address - Country:US
Mailing Address - Phone:707-823-5341
Mailing Address - Fax:707-823-8638
Practice Address - Street 1:6800 PALM AVE
Practice Address - Street 2:SUITE A
Practice Address - City:SEBASTOPOL
Practice Address - State:CA
Practice Address - Zip Code:95472-4269
Practice Address - Country:US
Practice Address - Phone:707-823-5341
Practice Address - Fax:707-823-8638
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-10
Last Update Date:2014-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAGO32795207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA45290Medicare UPIN
DL715ZMedicare PIN