Provider Demographics
NPI:1720211451
Name:DAVILA, THERESA A (PA-C)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:A
Last Name:DAVILA
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 1:105 VINECREST CT # 500
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:SC
Mailing Address - Zip Code:29646-8031
Mailing Address - Country:US
Mailing Address - Phone:864-725-7900
Mailing Address - Fax:864-725-7910
Practice Address - Street 1:105 VINECREST CT # 500
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:SC
Practice Address - Zip Code:29646-8031
Practice Address - Country:US
Practice Address - Phone:864-725-7900
Practice Address - Fax:864-725-7910
Is Sole Proprietor?:No
Enumeration Date:2009-08-28
Last Update Date:2023-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH1544363A00000X
TN1761363AS0400X
SC4837363A00000X
FLPA9110282363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4244049OtherBC/BS PA ASSIST AT SURG.
TN1515317Medicaid
TN4244068OtherBC/BS PA
TN4244068OtherBC/BS PA