Provider Demographics
NPI:1871986463
Name:DAVIDSON, BRIAN MARTIN (PA-C)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:MARTIN
Last Name:DAVIDSON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 S FRONT ST FL 6
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17104-1619
Mailing Address - Country:US
Mailing Address - Phone:717-988-9370
Mailing Address - Fax:
Practice Address - Street 1:205 S FRONT ST FL 6
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17104-1619
Practice Address - Country:US
Practice Address - Phone:717-988-9370
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-06
Last Update Date:2024-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0005709363A00000X
PAMA061366363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant