Healthcare Provider Details

I. General information

NPI: 1922592930
Provider Name (Legal Business Name): MICHAEL JOSEPH DAVIS PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2018
Last Update Date: 06/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 PARKER HILL AVENUE
BOSTON MA
02120
US

IV. Provider business mailing address

167 HEMLOCK RIDGE RD
SOUTHBURY CT
06488-3227
US

V. Phone/Fax

Practice location:
  • Phone: 617-754-5000
  • Fax:
Mailing address:
  • Phone: 203-695-2896
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: