Provider Demographics
NPI:1922115229
Name:DAVIS, MICHAEL E (PA-C)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:E
Last Name:DAVIS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:477 N EL CAMINO REAL
Mailing Address - Street 2:SUITE B301
Mailing Address - City:ENCINITAS
Mailing Address - State:CA
Mailing Address - Zip Code:92024-1328
Mailing Address - Country:US
Mailing Address - Phone:760-753-1104
Mailing Address - Fax:760-436-2075
Practice Address - Street 1:477 N EL CAMINO REAL
Practice Address - Street 2:SUITE B301
Practice Address - City:ENCINITAS
Practice Address - State:CA
Practice Address - Zip Code:92024-1328
Practice Address - Country:US
Practice Address - Phone:760-753-1104
Practice Address - Fax:760-436-2075
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-23
Last Update Date:2011-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA17532363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G448720Medicaid
CA00G448720Medicaid
CAQ71780Medicare UPIN