Provider Demographics
NPI:1962942839
Name:DAVIDSON, MARCUS RYAN (PA-C)
Entity type:Individual
Prefix:
First Name:MARCUS
Middle Name:RYAN
Last Name:DAVIDSON
Suffix:
Gender:M
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 1:605 SILVERSTONE RD STE 100
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-6899
Mailing Address - Country:US
Mailing Address - Phone:972-393-5559
Mailing Address - Fax:
Practice Address - Street 1:605 SILVERSTONE RD STE 100
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508
Practice Address - Country:US
Practice Address - Phone:337-266-9985
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-27
Last Update Date:2019-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA309327363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant