Provider Demographics
NPI:1457352486
Name:DAVIS, ROBERT (PA-C)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
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 1:789 WASHINGTON WEST
Mailing Address - Street 2:
Mailing Address - City:VALE
Mailing Address - State:OR
Mailing Address - Zip Code:97918
Mailing Address - Country:US
Mailing Address - Phone:541-473-2101
Mailing Address - Fax:541-473-2668
Practice Address - Street 1:789 WASHINGTON WEST
Practice Address - Street 2:
Practice Address - City:VALE
Practice Address - State:OR
Practice Address - Zip Code:97918
Practice Address - Country:US
Practice Address - Phone:541-473-2101
Practice Address - Fax:541-473-2668
Is Sole Proprietor?:No
Enumeration Date:2005-08-01
Last Update Date:2010-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA00345363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORP26844Medicare UPIN
ORR151295Medicare PIN
ORR109028Medicare PIN