Provider Demographics
NPI:1154352961
Name:DAVIS, DIANE MARIE (PAC)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:MARIE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6519 TURKEY RUN W
Mailing Address - Street 2:
Mailing Address - City:MEBANE
Mailing Address - State:NC
Mailing Address - Zip Code:27302-8652
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1313 HALLEY ST
Practice Address - Street 2:LYON PARK CLINIC
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27707-1227
Practice Address - Country:US
Practice Address - Phone:919-536-4205
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2022-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC101982363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant