Provider Demographics
NPI:1013948637
Name:DAVIS, MONICA AGNES (PA)
Entity Type:Individual
Prefix:
First Name:MONICA
Middle Name:AGNES
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 1:5547 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:VERONA
Mailing Address - State:NY
Mailing Address - Zip Code:13478-3426
Mailing Address - Country:US
Mailing Address - Phone:315-363-3482
Mailing Address - Fax:315-363-1957
Practice Address - Street 1:5547 W MAIN ST
Practice Address - Street 2:
Practice Address - City:VERONA
Practice Address - State:NY
Practice Address - Zip Code:13478-3426
Practice Address - Country:US
Practice Address - Phone:315-363-3482
Practice Address - Fax:315-363-1957
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2015-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003351363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY003351OtherP.A. LICENSE
NY01622444Medicaid
NYJ400194592Medicare PIN