Provider Demographics
NPI:1104887918
Name:DAVIDSON, SHANA ANN (PA-C)
Entity type:Individual
Prefix:MS
First Name:SHANA
Middle Name:ANN
Last Name:DAVIDSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:SHANA
Other - Middle Name:ANN
Other - Last Name:NELSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:240 W 11TH ST
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16501-1702
Mailing Address - Country:US
Mailing Address - Phone:814-452-2218
Mailing Address - Fax:814-452-4639
Practice Address - Street 1:240 W 11TH ST
Practice Address - Street 2:2ND FLOOR
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16501-1702
Practice Address - Country:US
Practice Address - Phone:814-452-2218
Practice Address - Fax:814-452-4639
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA051452363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA075034FTGMedicare PIN
PAQ01967Medicare UPIN