Basic Information
| Provider Information | |||||||||
| NPI: | 1407849201 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | CORI | ||||||||
| MiddleName: | MICHELLE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2106 W COVENTRY LN | ||||||||
| Address2: | |||||||||
| City: | ENOLA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 170251277 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7175149676 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3399 TRINDLE RD | ||||||||
| Address2: | |||||||||
| City: | CAMP HILL | ||||||||
| State: | PA | ||||||||
| PostalCode: | 170114407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7177615530 | ||||||||
| FaxNumber: | 7177377197 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/26/2005 | ||||||||
| LastUpdateDate: | 11/29/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | MA052373 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | MA052373 | 01 | PA | PA STATE LICENSE | OTHER | 1056473 | 01 | NCCPA CERTIFICATION | OTHER |