MEDICARE: SALLY ANN DAVIS PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	434	MT

General Provider Information

NPI Number	:	1558501411
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SALLY ANN DAVIS PA-C

Provider Business Mailing Address
First Line	:	1009 N WARREN ST
Second Line	:
City	:	HELENA
State	:	MT
Zip	:	59601-3454
Country	:	US
Telephone Number	:	406-443-2189
Fax Number	:

Provider Business Practice Location Address
First Line	:	3687 VETERANS DRIVE
Second Line	:	FORT HARRISON
City	:	HELENA
State	:	MT
Zip	:	59636
Country	:	US
Telephone Number	:	406-447-7564
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/04/2009
Last Update Date	:	03/04/2009

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