Provider Demographics
NPI:1639119738
Name:DAVINSON, JULIE A (PA-C)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:A
Last Name:DAVINSON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:JULIE
Other - Middle Name:A
Other - Last Name:LANDRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:13640 N PLAZA DEL RIO BLVD
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85381-4846
Mailing Address - Country:US
Mailing Address - Phone:623-876-3800
Mailing Address - Fax:623-972-9590
Practice Address - Street 1:13660 N 94TH DR
Practice Address - Street 2:STE C
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381-4836
Practice Address - Country:US
Practice Address - Phone:623-977-2400
Practice Address - Fax:623-977-7036
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-07
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2485363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ882870Medicaid
AZ882870Medicaid
AZP32966Medicare UPIN
AZ77426Medicare ID - Type UnspecifiedMDCR GRP WCFGW