Healthcare Provider Details

I. General information

NPI: 1316928682
Provider Name (Legal Business Name): BRYAN ANTHONY DAVIS PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2005
Last Update Date: 03/24/2021
Certification Date: 03/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

606 HIGHWAY 63 S
VIENNA MO
65582-8101
US

IV. Provider business mailing address

606 HIGHWAY 63 S
VIENNA MO
65582-8101
US

V. Phone/Fax

Practice location:
  • Phone: 573-422-3636
  • Fax: 573-422-3434
Mailing address:
  • Phone: 573-422-3636
  • Fax: 573-202-2433

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1300
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: