Provider Demographics
NPI:1477164580
Name:DAVIS, REBECCA DIANE (PA-C)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:DIANE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:PA-C
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 333
Mailing Address - Street 2:
Mailing Address - City:CARBON HILL
Mailing Address - State:AL
Mailing Address - Zip Code:35549-0333
Mailing Address - Country:US
Mailing Address - Phone:313-268-1453
Mailing Address - Fax:
Practice Address - Street 1:701 S. 19TH ST
Practice Address - Street 2:LHR 112
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35233
Practice Address - Country:US
Practice Address - Phone:205-934-5526
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-12
Last Update Date:2020-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPA1647363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant