Healthcare Provider Details

I. General information

NPI: 1205079514
Provider Name (Legal Business Name): ANNA DAVILA PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/16/2009
Last Update Date: 05/07/2025
Certification Date: 05/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 SYLVAN AVE STE A
MODESTO CA
95350-1699
US

IV. Provider business mailing address

1001 SYLVAN AVE STE A
MODESTO CA
95350-1699
US

V. Phone/Fax

Practice location:
  • Phone: 209-422-6120
  • Fax:
Mailing address:
  • Phone: 94-226-1202
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number013253
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: