Basic Information
| Provider Information | |||||||||
| NPI: | 1235609157 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVIDSON | ||||||||
| FirstName: | MAHRA | ||||||||
| MiddleName: | K. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | COLVIN | ||||||||
| OtherFirstName: | MAHRA | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 50095 | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981455095 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2065205700 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3800 MONTLAKE BLVD | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981950007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 0625205000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/04/2018 | ||||||||
| LastUpdateDate: | 02/12/2020 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/12/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | PA60930650 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 1235609157 | 05 | WA | MEDICAID |