Provider Demographics
NPI:1609389329
Name:DAVIDSON, CARRIE (PA)
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:
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 1:35200 BOB HOPE DR
Mailing Address - Street 2:
Mailing Address - City:RANCHO MIRAGE
Mailing Address - State:CA
Mailing Address - Zip Code:92270-1748
Mailing Address - Country:US
Mailing Address - Phone:760-328-8884
Mailing Address - Fax:760-202-3931
Practice Address - Street 1:35200 BOB HOPE DR
Practice Address - Street 2:
Practice Address - City:RANCHO MIRAGE
Practice Address - State:CA
Practice Address - Zip Code:92270-1748
Practice Address - Country:US
Practice Address - Phone:760-328-8884
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-16
Last Update Date:2021-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACA55091207NS0135X, 363A00000X
363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA55091OtherTHE MEDICAL BOARD OF CALIFORNIA
UT10535182-1206OtherSTATE OF UTAH DEPARTMENT OF COMMERCE
CAPA55091OtherTHE MEDICAL BOARD OF CALIFORNIA