Provider Demographics
NPI:1922109206
Name:DAVIS, COLLEEN (PA)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1306 N BROOM ST
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19806-4209
Mailing Address - Country:US
Mailing Address - Phone:302-571-9750
Mailing Address - Fax:302-571-0620
Practice Address - Street 1:1306 N BROOM ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19806-4209
Practice Address - Country:US
Practice Address - Phone:302-571-9750
Practice Address - Fax:302-571-0620
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2008-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC50000438363AS0400X
MDC03083363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE016022N04OtherRAILROAD MEDICARE
DEC50000438OtherDE LICENSE
MDC03083OtherMD STATE LICENSE
MD456P889GMedicare PIN
DEC50000438OtherDE LICENSE