Provider Demographics
NPI:1831912666
Name:DAVIS, GWYNETH (PA-C)
Entity type:Individual
Prefix:
First Name:GWYNETH
Middle Name:
Last Name:DAVIS
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 1:2919 W SWANN AVE STE 404
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33609-4052
Mailing Address - Country:US
Mailing Address - Phone:813-773-0579
Mailing Address - Fax:
Practice Address - Street 1:2919 W SWANN AVE STE 404
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33609-4052
Practice Address - Country:US
Practice Address - Phone:813-773-0579
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-31
Last Update Date:2024-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9119232363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant