Provider Demographics
NPI:1700091436
Name:DAVIS, BRETT (PA)
Entity Type:Individual
Prefix:
First Name:BRETT
Middle Name:
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 1:153 PIONEER LN STE B
Mailing Address - Street 2:
Mailing Address - City:BISHOP
Mailing Address - State:CA
Mailing Address - Zip Code:93514-2517
Mailing Address - Country:US
Mailing Address - Phone:760-873-2849
Mailing Address - Fax:760-873-2836
Practice Address - Street 1:41949 BIG BEAR BLVD
Practice Address - Street 2:
Practice Address - City:BIG BEAR LAKE
Practice Address - State:CA
Practice Address - Zip Code:92315
Practice Address - Country:US
Practice Address - Phone:909-878-3696
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-14
Last Update Date:2010-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA13662363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant