Basic Information
| Provider Information | |||||||||
| NPI: | 1104179183 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVIDSON | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | NOBLE | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1450 COLUMBUS AVE STE B 6-7-8 | ||||||||
| Address2: | |||||||||
| City: | WASHINGTON COURT HOUSE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 431603701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403332236 | ||||||||
| FaxNumber: | 7403333881 | ||||||||
| Practice Location | |||||||||
| Address1: | 1450 COLUMBUS AVE STE 103 | ||||||||
| Address2: | |||||||||
| City: | WASHINGTON COURT HOUSE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 431603701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403332243 | ||||||||
| FaxNumber: | 7403332248 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/16/2012 | ||||||||
| LastUpdateDate: | 07/14/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 0077380 | 05 | OH | MEDICAID |