Healthcare Provider Details

I. General information

NPI: 1396472833
Provider Name (Legal Business Name): TYLER DAVIS PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2022
Last Update Date: 09/28/2022
Certification Date: 09/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 S 20TH AVE
SAFFORD AZ
85546-4011
US

IV. Provider business mailing address

9276 COTTONWOOD WASH RD
PIMA AZ
85543-9617
US

V. Phone/Fax

Practice location:
  • Phone: 928-322-9353
  • Fax:
Mailing address:
  • Phone: 928-322-9353
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number9349
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: