Basic Information
| Provider Information | |||||||||
| NPI: | 1174284871 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | CAMERON | ||||||||
| MiddleName: | GREGORY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3340 E GOLDSTONE DR | ||||||||
| Address2: | |||||||||
| City: | MERIDIAN | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836421026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083029342 | ||||||||
| FaxNumber: | 2083675180 | ||||||||
| Practice Location | |||||||||
| Address1: | 315 E ELM ST STE 100 | ||||||||
| Address2: | |||||||||
| City: | CALDWELL | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836054858 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083027150 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/04/2022 | ||||||||
| LastUpdateDate: | 02/04/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 363A00000X | PA-2214 | ID | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.