Provider Demographics
NPI:1598429003
Name:DAVIDSON, SALLY ALEEN (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:SALLY
Middle Name:ALEEN
Last Name:DAVIDSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:SALLY
Other - Middle Name:ALEEN
Other - Last Name:HART
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:864-522-8603
Mailing Address - Fax:
Practice Address - Street 1:500 GILLS CREEK PKWY APT 416
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29209-1236
Practice Address - Country:US
Practice Address - Phone:919-896-3955
Practice Address - Fax:919-896-3955
Is Sole Proprietor?:No
Enumeration Date:2021-10-30
Last Update Date:2022-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
SC4211363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant