Provider Demographics
NPI:1740706670
Name:DAVISON, TIANA ANN
Entity type:Individual
Prefix:
First Name:TIANA
Middle Name:ANN
Last Name:DAVISON
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 1:254 E FERN AVE APT 106
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-6071
Mailing Address - Country:US
Mailing Address - Phone:801-664-4969
Mailing Address - Fax:
Practice Address - Street 1:33494 OAK GLEN RD
Practice Address - Street 2:
Practice Address - City:YUCAIPA
Practice Address - State:CA
Practice Address - Zip Code:92399-2057
Practice Address - Country:US
Practice Address - Phone:909-797-8900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-22
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA54993363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant