Healthcare Provider Details

I. General information

NPI: 1962979385
Provider Name (Legal Business Name): MARINA DAVOS PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/24/2018
Last Update Date: 03/05/2025
Certification Date: 03/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

81 RESERVOIR DR
ATHOL MA
01331-4901
US

IV. Provider business mailing address

49 REVOLUTION DR
LEOMINSTER MA
01453-2558
US

V. Phone/Fax

Practice location:
  • Phone: 978-248-5135
  • Fax: 978-248-5130
Mailing address:
  • Phone: 978-514-3641
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: