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General NPI Number Information
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NPI Number | 1205058948
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Entity Type | Individual
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Provider Name | BARTLETT EMORY DAVIS PAC ATC
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Gender | Male
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Dates
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Enumeration Date | 05/03/2007
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Last Update Date | 05/19/2021
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Provider Practice Location Address
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Address Line | 1707 MEADOWS LN SUITE H
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City | VIDALIA
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State | GA
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Zip | 30474-7200
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Country | US
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Telephone | 912-538-0040
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Fax | 912-538-8133
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Provider Business Mailing Address
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Address Line | PO BOX 1793
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City | VIDALIA
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State | GA
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Zip | 30475-1793
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Country | US
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Telephone | 912-538-9033
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | AT00981
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 1574
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License Number State | GA
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