Provider Demographics
NPI:1427000751
Name:DAVIS, CLIFFORD WAYNE (PAC)
Entity Type:Individual
Prefix:
First Name:CLIFFORD
Middle Name:WAYNE
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 1:3619 5TH AVE N
Mailing Address - Street 2:
Mailing Address - City:GREAT FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59401-2207
Mailing Address - Country:US
Mailing Address - Phone:406-271-3211
Mailing Address - Fax:
Practice Address - Street 1:805 SUNSET BLVD
Practice Address - Street 2:P O 758
Practice Address - City:CONRAD
Practice Address - State:MT
Practice Address - Zip Code:59425-1717
Practice Address - Country:US
Practice Address - Phone:406-271-3211
Practice Address - Fax:406-271-7661
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2021-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT301363A00000X
COPA0004597363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MTP56957Medicare UPIN