Provider Demographics
NPI:1477989424
Name:DAVIDSON, BROOKE ALISON
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:ALISON
Last Name:DAVIDSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26908 INDEPENDENCE WAY
Mailing Address - Street 2:
Mailing Address - City:EVANS MILLS
Mailing Address - State:NY
Mailing Address - Zip Code:13637-3300
Mailing Address - Country:US
Mailing Address - Phone:315-782-6900
Mailing Address - Fax:315-782-2581
Practice Address - Street 1:26908 INDEPENDENCE WAY
Practice Address - Street 2:
Practice Address - City:EVANS MILLS
Practice Address - State:NY
Practice Address - Zip Code:13637-3300
Practice Address - Country:US
Practice Address - Phone:315-782-6900
Practice Address - Fax:315-782-2581
Is Sole Proprietor?:No
Enumeration Date:2013-09-23
Last Update Date:2024-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016929363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01995615Medicaid
AA0564Medicare PIN