Basic Information
| Provider Information | |||||||||
| NPI: | 1295214047 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DAVIDSON | ||||||||
| FirstName: | JOHNATHAN | ||||||||
| MiddleName: | O'NEIL | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 AIRPORT GARDENS RD STE 311 | ||||||||
| Address2: | |||||||||
| City: | HAZARD | ||||||||
| State: | KY | ||||||||
| PostalCode: | 417019529 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6064396978 | ||||||||
| FaxNumber: | 6064396927 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 MEDICAL CENTER DR | ||||||||
| Address2: | |||||||||
| City: | HAZARD | ||||||||
| State: | KY | ||||||||
| PostalCode: | 41701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6064396779 | ||||||||
| FaxNumber: | 6064878448 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/13/2018 | ||||||||
| LastUpdateDate: | 08/13/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | TC729 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.