Provider Demographics
NPI:1548201007
Name:DAVIS, TISH D (PA-C)
Entity Type:Individual
Prefix:
First Name:TISH
Middle Name:D
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 1:425 W BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-6035
Mailing Address - Country:US
Mailing Address - Phone:208-343-1702
Mailing Address - Fax:208-342-7042
Practice Address - Street 1:2235 E GALA ST
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-8026
Practice Address - Country:US
Practice Address - Phone:208-887-3724
Practice Address - Fax:208-887-1682
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2019-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA1576363AM0700X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical