Provider Demographics
NPI:1831204676
Name:DAVIS, MERCEDES ZIMMERMAN (PA-C)
Entity type:Individual
Prefix:
First Name:MERCEDES
Middle Name:ZIMMERMAN
Last Name:DAVIS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MERCEDES
Other - Middle Name:ANNA
Other - Last Name:ZIMMERMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:106 LANSFORD PL
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29588-6979
Mailing Address - Country:US
Mailing Address - Phone:843-293-8850
Mailing Address - Fax:843-293-8860
Practice Address - Street 1:106 LANSFORD PL
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29588-6979
Practice Address - Country:US
Practice Address - Phone:843-293-8850
Practice Address - Fax:843-293-8860
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-20
Last Update Date:2016-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC001000495363A00000X
PAMA054212363A00000X
SCPA2292363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCQ75651Medicare UPIN