Provider Demographics
NPI:1285864991
Name:DAVANZO, MICHAEL JAMES (PA-C)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:JAMES
Last Name:DAVANZO
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:PO BOX 602362
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-2362
Mailing Address - Country:US
Mailing Address - Phone:336-765-2500
Mailing Address - Fax:336-765-2555
Practice Address - Street 1:346 W GOLDENEYE LN
Practice Address - Street 2:
Practice Address - City:SNEADS FERRY
Practice Address - State:NC
Practice Address - Zip Code:28460-8096
Practice Address - Country:US
Practice Address - Phone:336-682-6654
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-16
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-01885363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8101359Medicaid
NC2760119CMedicare PIN