Provider Demographics
NPI:1922068212
Name:DAVIS, JAMES BRADLEY (PA-C)
Entity Type:Individual
Prefix:MR
First Name:JAMES
Middle Name:BRADLEY
Last Name:DAVIS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5770 SOUTH 250 EAST
Mailing Address - Street 2:SUITE 135
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-8241
Mailing Address - Country:US
Mailing Address - Phone:801-314-2225
Mailing Address - Fax:801-314-2345
Practice Address - Street 1:5770 SOUTH 250 EAST
Practice Address - Street 2:SUITE 135
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84107-8241
Practice Address - Country:US
Practice Address - Phone:801-314-2225
Practice Address - Fax:801-314-2345
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2014-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT103792-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000012014Medicare ID - Type Unspecified