Provider Demographics
NPI:1871589457
Name:DAVIDSON, MARSHA RAE (FNP)
Entity type:Individual
Prefix:
First Name:MARSHA
Middle Name:RAE
Last Name:DAVIDSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:MARSHA
Other - Middle Name:RAE
Other - Last Name:MAYBERRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:1508 DIVISION ST
Mailing Address - Street 2:STE 15
Mailing Address - City:OREGON CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97045-1582
Mailing Address - Country:US
Mailing Address - Phone:503-657-5555
Mailing Address - Fax:503-657-6502
Practice Address - Street 1:1508 DIVISION ST
Practice Address - Street 2:STE 15
Practice Address - City:OREGON CITY
Practice Address - State:OR
Practice Address - Zip Code:97045-1582
Practice Address - Country:US
Practice Address - Phone:503-657-5555
Practice Address - Fax:503-657-6502
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR100290Medicaid
115247Medicare ID - Type Unspecified
OR100290Medicaid