Provider Demographics
NPI:1780666503
Name:DAVIDSON, RICHARD W (PA)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:W
Last Name:DAVIDSON
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 1:1203 OLD QUAKER RD
Mailing Address - Street 2:
Mailing Address - City:GALAX
Mailing Address - State:VA
Mailing Address - Zip Code:24333-5520
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:911 E MAIN ST
Practice Address - Street 2:
Practice Address - City:FLOYD
Practice Address - State:VA
Practice Address - Zip Code:24091-4183
Practice Address - Country:US
Practice Address - Phone:540-745-2031
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-17
Last Update Date:2008-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110-000021363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010083923Medicaid
VAQ22980Medicare UPIN
VA005369C86Medicare PIN
VA010083923Medicaid