Basic Information
| Provider Information | |||||||||
| NPI: | 1477656379 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | SHARI | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9718 S HALSTED ST | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606281007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7732982056 | ||||||||
| FaxNumber: | 7732334055 | ||||||||
| Practice Location | |||||||||
| Address1: | 9718 S. HALSTED | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60628 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7732334100 | ||||||||
| FaxNumber: | 7732338542 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/06/2006 | ||||||||
| LastUpdateDate: | 04/23/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 085001968 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 085001968 | 05 | IL | MEDICAID |