Provider Demographics
NPI:1760486633
Name:DAVIS, MARTHA J (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:MARTHA
Middle Name:J
Last Name:DAVIS
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 1:4546 NC HIGHWAY 87 S
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:NC
Mailing Address - Zip Code:27332-0212
Mailing Address - Country:US
Mailing Address - Phone:919-499-5151
Mailing Address - Fax:919-499-5147
Practice Address - Street 1:4546 NC HIGHWAY 87 S
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:NC
Practice Address - Zip Code:27332-0212
Practice Address - Country:US
Practice Address - Phone:919-499-5151
Practice Address - Fax:919-499-5147
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2011-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC101896363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCP00222253OtherRAILROAD MEDICARE
NCP00460275OtherRAILROAD MEDICARE
NC26-0645258OtherTRICARE
NCP00222253OtherRAILROAD MEDICARE
NCP00460275OtherRAILROAD MEDICARE
S26189Medicare UPIN