Healthcare Provider Details

I. General information

NPI: 1508946351
Provider Name (Legal Business Name): BRIAN MARK DAVIS P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/16/2006
Last Update Date: 10/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2510 AIRPARK DR STE 301
REDDING CA
96001-2462
US

IV. Provider business mailing address

3400 DATA DR ATTN CREDENTIALING/PAYER ENROLLMENT
RANCHO CORDOVA CA
95670-7956
US

V. Phone/Fax

Practice location:
  • Phone: 530-242-3500
  • Fax: 530-242-3546
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA 18631
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: