=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730337858
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CORY STEPHEN DAVENPORT PA-C
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/03/2008
-----------------------------------------------------
Last Update Date | 02/06/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1200 N BEAVER ST
-----------------------------------------------------
City | FLAGSTAFF
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86001-3118
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-773-2332
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7259 S BINGHAM JUNCTION BLVD
-----------------------------------------------------
City | MIDVALE
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84047-4860
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 866-615-5536
-----------------------------------------------------
Fax | 866-588-4301
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AS0400X
-----------------------------------------------------
Taxonomy Name | Surgical Physician Assistant
-----------------------------------------------------
License Number | 55215
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363AS0400X
-----------------------------------------------------
Taxonomy Name | Surgical Physician Assistant
-----------------------------------------------------
License Number | 10807
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------