Provider Demographics
NPI:1790704062
Name:DAVIS, DENISE ROSE (PA)
Entity Type:Individual
Prefix:MRS
First Name:DENISE
Middle Name:ROSE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MS
Other - First Name:DENISE
Other - Middle Name:ROSE
Other - Last Name:GALLAGHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:27483 DEQUINDRE RD
Mailing Address - Street 2:SUITE 314
Mailing Address - City:MADISON HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48071-3491
Mailing Address - Country:US
Mailing Address - Phone:248-547-6600
Mailing Address - Fax:248-547-5696
Practice Address - Street 1:27483 DEQUINDRE RD
Practice Address - Street 2:SUITE 314
Practice Address - City:MADISON HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48071-3491
Practice Address - Country:US
Practice Address - Phone:248-547-6600
Practice Address - Fax:248-547-5696
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2014-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601004747363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI700H217350OtherBLUE SHIELD
MI1790704062Medicaid
MI0M92440069Medicare PIN
MIQ71149Medicare UPIN