Provider Demographics
NPI:1285771808
Name:DAVIS, DERRICK ANTHONY (MPH, PA-C)
Entity type:Individual
Prefix:MR
First Name:DERRICK
Middle Name:ANTHONY
Last Name:DAVIS
Suffix:
Gender:M
Credentials:MPH, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 S FLAMINGO RD
Mailing Address - Street 2:# 112
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33027-1770
Mailing Address - Country:US
Mailing Address - Phone:954-558-6324
Mailing Address - Fax:
Practice Address - Street 1:320 S FLAMINGO RD
Practice Address - Street 2:# 112
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33027-1770
Practice Address - Country:US
Practice Address - Phone:954-558-6324
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2013-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9103680363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical