Provider Demographics
NPI:1619227592
Name:DAVENPORT, AMBER NOEL (PA-C)
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:NOEL
Last Name:DAVENPORT
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 1:825 N CENTER AVENUE
Mailing Address - Street 2:
Mailing Address - City:GAYLORD
Mailing Address - State:MI
Mailing Address - Zip Code:49735
Mailing Address - Country:US
Mailing Address - Phone:989-731-7708
Mailing Address - Fax:989-731-7929
Practice Address - Street 1:245 W CENTRE AVE
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-5331
Practice Address - Country:US
Practice Address - Phone:269-323-2450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-18
Last Update Date:2020-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601006455363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical