Provider Demographics
NPI:1366509416
Name:DAVIS, L BRENT (PA-C)
Entity type:Individual
Prefix:
First Name:L
Middle Name:BRENT
Last Name:DAVIS
Suffix:
Gender:M
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 1:801 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WEST LIBERTY
Mailing Address - State:KY
Mailing Address - Zip Code:41472-1021
Mailing Address - Country:US
Mailing Address - Phone:606-743-1422
Mailing Address - Fax:
Practice Address - Street 1:801 N. MAIN STR.
Practice Address - Street 2:FAITH FAMILY PRACTICE
Practice Address - City:WEST LIBERTY
Practice Address - State:KY
Practice Address - Zip Code:41472-1021
Practice Address - Country:US
Practice Address - Phone:606-743-1422
Practice Address - Fax:606-743-1455
Is Sole Proprietor?:No
Enumeration Date:2007-01-01
Last Update Date:2010-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA120363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
R17186Medicare UPIN