Provider Demographics
NPI:1366934382
Name:DAVIES, ADRIAN RICKETTS (PA)
Entity type:Individual
Prefix:
First Name:ADRIAN
Middle Name:RICKETTS
Last Name:DAVIES
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:ADRIAN
Other - Middle Name:KELLY
Other - Last Name:RICKETTS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:6419 BRISTOL HWY
Mailing Address - Street 2:
Mailing Address - City:PINEY FLATS
Mailing Address - State:TN
Mailing Address - Zip Code:37686-5208
Mailing Address - Country:US
Mailing Address - Phone:615-202-3359
Mailing Address - Fax:
Practice Address - Street 1:550 SUNSET TRL
Practice Address - Street 2:
Practice Address - City:JELLICO
Practice Address - State:TN
Practice Address - Zip Code:37762-2343
Practice Address - Country:US
Practice Address - Phone:615-202-3359
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-05
Last Update Date:2022-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYTC954363A00000X
TN1151615363A00000X
TN3603363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYTC954OtherSTATE LICENSE
TNQ045211Medicaid
TN3603OtherSTATE LICENSE
KY7100690300Medicaid
TN3603OtherSTATE LICENSE