Provider Demographics
NPI:1619033446
Name:DAVIS, JILL (PA)
Entity Type:Individual
Prefix:MS
First Name:JILL
Middle Name:
Last Name:DAVIS
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:DUMC 3158
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27710-0001
Mailing Address - Country:US
Mailing Address - Phone:919-684-5118
Mailing Address - Fax:919-668-1559
Practice Address - Street 1:DUMC 3158
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27710-0001
Practice Address - Country:US
Practice Address - Phone:919-684-5118
Practice Address - Fax:919-668-1559
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2009-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085-002554363A00000X
NC0010-01654363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL3932056OtherBCBS
IL7210895OtherAETNA
IL733354OtherHEALTHLINK
IL109260OtherHAMP INS. #
IL109260OtherHAMP INS. #
IL3932056OtherBCBS
IL733354OtherHEALTHLINK
IL7210895OtherAETNA
ILQ62437Medicare UPIN
ILK24811Medicare ID - Type UnspecifiedMEDICARE INDIVIDUAL #