Provider Demographics
NPI:1508893652
Name:DAVIS, JEFFREY RICHARDS (PA-C)
Entity Type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:RICHARDS
Last Name:DAVIS
Suffix:
Gender:M
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 257
Mailing Address - Street 2:
Mailing Address - City:SOUTH RIM
Mailing Address - State:UT
Mailing Address - Zip Code:84071-0257
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1244 N MAIN ST STE 201
Practice Address - Street 2:
Practice Address - City:TOOELE
Practice Address - State:UT
Practice Address - Zip Code:84074-9839
Practice Address - Country:US
Practice Address - Phone:435-849-4155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2013-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6198492-1206207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WADAV1957Medicare UPIN