Healthcare Provider Details

I. General information

NPI: 1437567039
Provider Name (Legal Business Name): ANDREA DAVIS PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ANDREA COY

II. Dates (important events)

Enumeration Date: 07/27/2014
Last Update Date: 06/18/2025
Certification Date: 06/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 E BROADWAY ST BOX 236
WETUMKA OK
74883-4505
US

IV. Provider business mailing address

6839 S CANTON AVE
TULSA OK
74136-3402
US

V. Phone/Fax

Practice location:
  • Phone: 405-452-3151
  • Fax:
Mailing address:
  • Phone: 918-494-0612
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2399
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: