Provider Demographics
NPI:1578517876
Name:DAVIDSON, MELISSA M (PA)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:M
Last Name:DAVIDSON
Suffix:
Gender:F
Credentials:PA
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 2968
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30156-9117
Mailing Address - Country:US
Mailing Address - Phone:770-779-0015
Mailing Address - Fax:
Practice Address - Street 1:4800 OLDE TOWNE PKWY STE 150A
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30068-4357
Practice Address - Country:US
Practice Address - Phone:770-509-1025
Practice Address - Fax:770-509-1884
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2021-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA002192363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA100001575BMedicaid
GA10038125OtherAMERIGROUP
GA333457OtherWELLCARE
GA100001575CMedicaid
GA100001575Medicaid
GA10038125OtherAMERIGROUP
GAP00119627Medicare PIN
R68848Medicare UPIN
GA100001575BMedicaid