Healthcare Provider Details

I. General information

NPI: 1710380795
Provider Name (Legal Business Name): JAKE A DAVIS PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2014
Last Update Date: 01/07/2025
Certification Date: 01/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9600 BROADWAY EXT
OKLAHOMA CITY OK
73114-7408
US

IV. Provider business mailing address

300 PERSHING AVVENUE
SHENANDOAH IA
51601
US

V. Phone/Fax

Practice location:
  • Phone: 405-230-9000
  • Fax:
Mailing address:
  • Phone: 712-246-7101
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number074782
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: