Provider Demographics
NPI:1942328984
Name:DAVIS, AUTUMN DEESE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:AUTUMN
Middle Name:DEESE
Last Name:DAVIS
Suffix:
Gender:F
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 1:401 DIXIE ST
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30117-3921
Mailing Address - Country:US
Mailing Address - Phone:678-796-0681
Mailing Address - Fax:770-836-8477
Practice Address - Street 1:401 DIXIE ST
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117-3921
Practice Address - Country:US
Practice Address - Phone:678-796-0681
Practice Address - Fax:770-836-8477
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2014-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1075178363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant