Provider Demographics
NPI:1760561963
Name:DAVIS, MARK G (PA)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:G
Last Name:DAVIS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1519 S PHILLIPS ST
Mailing Address - Street 2:
Mailing Address - City:ALGONA
Mailing Address - State:IA
Mailing Address - Zip Code:50511-3649
Mailing Address - Country:US
Mailing Address - Phone:515-295-7714
Mailing Address - Fax:515-295-4505
Practice Address - Street 1:1519 S PHILLIPS ST
Practice Address - Street 2:
Practice Address - City:ALGONA
Practice Address - State:IA
Practice Address - Zip Code:50511-3649
Practice Address - Country:US
Practice Address - Phone:515-295-7714
Practice Address - Fax:515-295-4505
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2020-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA000685363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA06226OtherWELLMARK
IA36655OtherWELLMARK
IA06226OtherWELLMARK