Provider Demographics
NPI:1760488571
Name:DAVIS, BRIAN W (PA-C)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:W
Last Name:DAVIS
Suffix:
Gender:M
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:PO BOX 1921
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80150-1921
Mailing Address - Country:US
Mailing Address - Phone:970-241-0202
Mailing Address - Fax:970-245-0250
Practice Address - Street 1:360 PEAK ONE DRIVE
Practice Address - Street 2:STE 180
Practice Address - City:FRISCO
Practice Address - State:CO
Practice Address - Zip Code:80443
Practice Address - Country:US
Practice Address - Phone:970-668-3633
Practice Address - Fax:970-668-4406
Is Sole Proprietor?:No
Enumeration Date:2005-06-27
Last Update Date:2014-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO841363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO680501385006OtherRMHP ID
CODA252309OtherBLUE CROSS BLUE SHIELD ID
CO466998Medicare ID - Type Unspecified
COS35321Medicare UPIN