Provider Demographics
NPI:1659755866
Name:DAVIES, COLTON D (PA-C)
Entity Type:Individual
Prefix:
First Name:COLTON
Middle Name:D
Last Name:DAVIES
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:COLTON
Other - Middle Name:
Other - Last Name:PUGH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:9000 W WISCONSIN AVE
Mailing Address - Street 2:PEDIATRIC CARDIOTHORACIC SURGERY
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-4874
Mailing Address - Country:US
Mailing Address - Phone:414-266-2380
Mailing Address - Fax:414-266-2294
Practice Address - Street 1:9000 W WISCONSIN AVE
Practice Address - Street 2:PEDIATRIC CARDIOTHORACIC SURGERY
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-4874
Practice Address - Country:US
Practice Address - Phone:414-266-2380
Practice Address - Fax:414-266-2294
Is Sole Proprietor?:No
Enumeration Date:2015-07-17
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3973363AS0400X
COPA.0006928363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1659755866Medicaid