Provider Demographics
NPI:1538686068
Name:FORMAN, DAVITA PAULA (PA-C)
Entity type:Individual
Prefix:
First Name:DAVITA
Middle Name:PAULA
Last Name:FORMAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2553 JARDIN TER
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:FL
Mailing Address - Zip Code:33327-1519
Mailing Address - Country:US
Mailing Address - Phone:954-816-0832
Mailing Address - Fax:
Practice Address - Street 1:1255 CREEKSHIRE WAY
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-3059
Practice Address - Country:US
Practice Address - Phone:336-701-3111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-25
Last Update Date:2017-08-25
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant