Provider Demographics
NPI:1538542402
Name:DAVIDSON, KERRY
Entity type:Individual
Prefix:
First Name:KERRY
Middle Name:
Last Name:DAVIDSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1333 TAYLOR ST STE 6B
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29201-2953
Mailing Address - Country:US
Mailing Address - Phone:803-251-3093
Mailing Address - Fax:803-376-1876
Practice Address - Street 1:1333 TAYLOR ST STE 6B
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201-2953
Practice Address - Country:US
Practice Address - Phone:803-251-3093
Practice Address - Fax:803-376-1876
Is Sole Proprietor?:No
Enumeration Date:2015-07-09
Last Update Date:2025-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4507363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical