Provider Demographics
NPI:1285720409
Name:DAVIS, ELIZABETH CANNON (PAC)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:CANNON
Last Name:DAVIS
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:
Other - Last Name:CANNON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:1450 TREAT BLVD
Mailing Address - Street 2:STE 300
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94597-2168
Mailing Address - Country:US
Mailing Address - Phone:510-334-2098
Mailing Address - Fax:
Practice Address - Street 1:1450 TREAT BLVD STE 160
Practice Address - Street 2:
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94597-2168
Practice Address - Country:US
Practice Address - Phone:925-296-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2018-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA54622363AM0700X
CAPA17569363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA68-0360801Medicaid