Provider Demographics
NPI:1194775981
Name:DAVIDSON, RIKI (PA-C)
Entity type:Individual
Prefix:
First Name:RIKI
Middle Name:
Last Name:DAVIDSON
Suffix:
Gender:F
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 1:15510 E TELEGRAPH DR
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN HILLS
Mailing Address - State:AZ
Mailing Address - Zip Code:85268-4937
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:300 W CLARENDON AVE STE 440
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85013-3476
Practice Address - Country:US
Practice Address - Phone:602-266-9066
Practice Address - Fax:602-266-5711
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2019-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2964363A00000X
TXPA07314363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ2964OtherLICENSE
TXPA07314OtherLICENSE
TX288198903Medicaid