Provider Demographics
NPI:1932566379
Name:DAVIS, BRENNA (PA-C)
Entity Type:Individual
Prefix:
First Name:BRENNA
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1310 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:WISCONSIN DELLS
Mailing Address - State:WI
Mailing Address - Zip Code:53965-1358
Mailing Address - Country:US
Mailing Address - Phone:608-253-1171
Mailing Address - Fax:608-253-8012
Practice Address - Street 1:1310 BROADWAY
Practice Address - Street 2:
Practice Address - City:WISCONSIN DELLS
Practice Address - State:WI
Practice Address - Zip Code:53965-1358
Practice Address - Country:US
Practice Address - Phone:608-253-1171
Practice Address - Fax:608-253-8012
Is Sole Proprietor?:No
Enumeration Date:2016-01-15
Last Update Date:2022-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD1015363A00000X
WI5784-23363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1932566379Medicaid