Healthcare Provider Details

I. General information

NPI: 1790892438
Provider Name (Legal Business Name): ROBERT P. DAVIS PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 DEERWOOD AVE NW
WADENA MN
56482-1253
US

IV. Provider business mailing address

4 DEERWOOD AVE NW
WADENA MN
56482-1253
US

V. Phone/Fax

Practice location:
  • Phone: 218-631-1360
  • Fax: 218-631-7571
Mailing address:
  • Phone: 218-631-1360
  • Fax: 218-631-7571

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number8808
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: