Provider Demographics
NPI:1558132969
Name:DAVIS, MYKAELA (PA)
Entity type:Individual
Prefix:
First Name:MYKAELA
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1565 S PLEASANTS HWY
Mailing Address - Street 2:
Mailing Address - City:SAINT MARYS
Mailing Address - State:WV
Mailing Address - Zip Code:26170-9055
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1861 N PLEASANTS HWY # 101
Practice Address - Street 2:
Practice Address - City:SAINT MARYS
Practice Address - State:WV
Practice Address - Zip Code:26170-8511
Practice Address - Country:US
Practice Address - Phone:681-612-1022
Practice Address - Fax:304-447-2556
Is Sole Proprietor?:No
Enumeration Date:2024-01-15
Last Update Date:2024-09-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WV2925363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant