Healthcare Provider Details

I. General information

NPI: 1760561963
Provider Name (Legal Business Name): MARK G DAVIS PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2006
Last Update Date: 07/08/2020
Certification Date: 07/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1519 S PHILLIPS ST
ALGONA IA
50511-3649
US

IV. Provider business mailing address

1519 S PHILLIPS ST
ALGONA IA
50511-3649
US

V. Phone/Fax

Practice location:
  • Phone: 515-295-7714
  • Fax: 515-295-4505
Mailing address:
  • Phone: 515-295-7714
  • Fax: 515-295-4505

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number000685
License Number StateIA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier06226
Identifier TypeOTHER
Identifier StateIA
Identifier IssuerWELLMARK
# 2
Identifier36655
Identifier TypeOTHER
Identifier StateIA
Identifier IssuerWELLMARK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: