Provider Demographics
NPI:1902348451
Name:EATON, MARCY DAVENPORT (PA-C)
Entity Type:Individual
Prefix:
First Name:MARCY
Middle Name:DAVENPORT
Last Name:EATON
Suffix:
Gender:F
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 1:678 FILLGATE DR
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27104-3366
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:935 SHOTWELL RD
Practice Address - Street 2:SUITE 108
Practice Address - City:CLAYTON
Practice Address - State:NC
Practice Address - Zip Code:27520-5597
Practice Address - Country:US
Practice Address - Phone:919-359-2667
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-15
Last Update Date:2024-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-06816363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant