Provider Demographics
NPI:1508928714
Name:DAVIS, MARK C (PA)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:C
Last Name:DAVIS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 C AVE
Mailing Address - Street 2:
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97034-2353
Mailing Address - Country:US
Mailing Address - Phone:503-905-9006
Mailing Address - Fax:503-238-0841
Practice Address - Street 1:123 C AVE
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97034-2353
Practice Address - Country:US
Practice Address - Phone:503-905-9006
Practice Address - Fax:503-238-0841
Is Sole Proprietor?:No
Enumeration Date:2006-12-14
Last Update Date:2024-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA01047363AS0400X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR044615Medicaid
132420Medicare ID - Type Unspecified
OR044615Medicaid