Healthcare Provider Details

I. General information

NPI: 1639934193
Provider Name (Legal Business Name): KORTNI MICHELLE DAVIS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/14/2024
Last Update Date: 02/20/2026
Certification Date: 02/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

96 JONATHAN LUCAS ST
CHARLESTON SC
29425-8900
US

IV. Provider business mailing address

6607 BUTTERCUP DR
CHEYENNE WY
82009-5718
US

V. Phone/Fax

Practice location:
  • Phone: 843-792-1414
  • Fax:
Mailing address:
  • Phone: 307-286-6894
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: