Provider Demographics
NPI:1477656379
Name:DAVIS, SHARI M (PA-C)
Entity Type:Individual
Prefix:MS
First Name:SHARI
Middle Name:M
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 1:9718 S HALSTED ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60628-1007
Mailing Address - Country:US
Mailing Address - Phone:773-298-2056
Mailing Address - Fax:773-233-4055
Practice Address - Street 1:9718 S. HALSTED
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60628
Practice Address - Country:US
Practice Address - Phone:773-233-4100
Practice Address - Fax:773-233-8542
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2013-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085001968363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL085001968Medicaid
ILK16576Medicare ID - Type Unspecified
IL085001968Medicaid