Provider Demographics
NPI:1629887518
Name:DAVIS, LISA MICHELLE (PHD, PA-C)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:MICHELLE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:PHD, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3950 WHITE ROSE WAY
Mailing Address - Street 2:
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21042-5822
Mailing Address - Country:US
Mailing Address - Phone:443-865-5342
Mailing Address - Fax:
Practice Address - Street 1:3950 WHITE ROSE WAY
Practice Address - Street 2:
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21042-5822
Practice Address - Country:US
Practice Address - Phone:443-865-5342
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-06
Last Update Date:2025-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0002863207R00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine