Healthcare Provider Details

I. General information

NPI: 1720211451
Provider Name (Legal Business Name): THERESA A DAVILA PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2009
Last Update Date: 06/24/2025
Certification Date: 06/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1506 SPRING ST
GREENWOOD SC
29646-4071
US

IV. Provider business mailing address

12251 S 80TH AVE STE 1520
PALOS HEIGHTS IL
60463-1290
US

V. Phone/Fax

Practice location:
  • Phone: 864-725-7900
  • Fax: 864-725-7910
Mailing address:
  • Phone: 708-923-4200
  • Fax: 708-923-4201

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9110282
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1544
License Number StateNH
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number4837
License Number StateSC
# 4
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number1761
License Number StateTN
# 5
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085011269
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: