Provider Demographics
NPI:1487747713
Name:DAVIS, MARK L (PA-C)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:L
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:PO BOX 849
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE
Mailing Address - State:OK
Mailing Address - Zip Code:74802-0849
Mailing Address - Country:US
Mailing Address - Phone:405-273-5801
Mailing Address - Fax:495-878-3814
Practice Address - Street 1:3315 KETHLEY RD
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:OK
Practice Address - Zip Code:74804-9638
Practice Address - Country:US
Practice Address - Phone:405-273-5801
Practice Address - Fax:405-878-3814
Is Sole Proprietor?:No
Enumeration Date:2006-09-30
Last Update Date:2012-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKPA801363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100715900BMedicaid
S37498Medicare UPIN
OK100715900BMedicaid