Provider Demographics
NPI:1528146073
Name:DAVIS, JACQUE FALK (PA-C)
Entity type:Individual
Prefix:
First Name:JACQUE
Middle Name:FALK
Last Name:DAVIS
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 1:3521 NW SAMARITAN DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97330-4744
Mailing Address - Country:US
Mailing Address - Phone:541-768-6119
Mailing Address - Fax:541-768-6120
Practice Address - Street 1:3521 NW SAMARITAN DR
Practice Address - Street 2:SUITE 101
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-4744
Practice Address - Country:US
Practice Address - Phone:541-768-6119
Practice Address - Fax:541-768-6120
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2012-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA00875363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORP95223Medicare UPIN
OR133667Medicare ID - Type UnspecifiedMEDICARE