Provider Demographics
NPI:1700386232
Name:DAVIS, AMANDA SUSAN (PA)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:SUSAN
Last Name:DAVIS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:SUSAN
Other - Last Name:BRADLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:363 FREMONT ST STE 203
Mailing Address - Street 2:
Mailing Address - City:BATTLE CREEK
Mailing Address - State:MI
Mailing Address - Zip Code:49017-3398
Mailing Address - Country:US
Mailing Address - Phone:269-969-6123
Mailing Address - Fax:269-969-6122
Practice Address - Street 1:363 FREMONT ST STE 203
Practice Address - Street 2:
Practice Address - City:BATTLE CREEK
Practice Address - State:MI
Practice Address - Zip Code:49017-3398
Practice Address - Country:US
Practice Address - Phone:269-969-6123
Practice Address - Fax:269-969-6122
Is Sole Proprietor?:No
Enumeration Date:2018-02-21
Last Update Date:2021-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601008581363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical