Healthcare Provider Details

I. General information

NPI: 1629758727
Provider Name (Legal Business Name): TYRA ALYSSA DAVIS PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2023
Last Update Date: 08/14/2026
Certification Date: 08/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2555 COURT DR STE 450
GASTONIA NC
28054-2191
US

IV. Provider business mailing address

2555 COURT DR STE 450
GASTONIA NC
28054-2191
US

V. Phone/Fax

Practice location:
  • Phone: 704-671-7652
  • Fax: 704-671-7656
Mailing address:
  • Phone: 704-671-7652
  • Fax: 704-671-7656

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-15712
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPAT9117863
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: