Provider Demographics
NPI:1588150916
Name:ANNIS, DAVIKA SERENE (PA-C)
Entity type:Individual
Prefix:MS
First Name:DAVIKA
Middle Name:SERENE
Last Name:ANNIS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:DAVIKA
Other - Middle Name:SERENE
Other - Last Name:RICHTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4300 MARKETPOINTE DR STE 100
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55435-5435
Mailing Address - Country:US
Mailing Address - Phone:952-835-9880
Mailing Address - Fax:952-857-1554
Practice Address - Street 1:4300 MARKETPOINTE DR STE 100
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55435-5435
Practice Address - Country:US
Practice Address - Phone:952-835-9880
Practice Address - Fax:952-857-1554
Is Sole Proprietor?:No
Enumeration Date:2018-07-09
Last Update Date:2022-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN13152363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant