Provider Demographics
NPI:1699382440
Name:DAVIDSON, DAVID ALLEN (PA)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:ALLEN
Last Name:DAVIDSON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4300 W 7TH ST
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-5446
Mailing Address - Country:US
Mailing Address - Phone:501-257-1000
Mailing Address - Fax:
Practice Address - Street 1:476 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:CAMDEN
Practice Address - State:AR
Practice Address - Zip Code:71701-4616
Practice Address - Country:US
Practice Address - Phone:870-800-9002
Practice Address - Fax:870-800-9004
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-25
Last Update Date:2024-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
ARPA-939363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR257653795Medicaid