Healthcare Provider Details

I. General information

NPI: 1487747713
Provider Name (Legal Business Name): MARK L. DAVIS P.A.-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2006
Last Update Date: 08/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3315 KETHLEY RD
SHAWNEE OK
74804-9638
US

IV. Provider business mailing address

PO BOX 849
SHAWNEE OK
74802-0849
US

V. Phone/Fax

Practice location:
  • Phone: 405-273-5801
  • Fax: 405-878-3814
Mailing address:
  • Phone: 405-273-5801
  • Fax: 495-878-3814

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA801
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: