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General NPI Number Information
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NPI Number | 1861013583
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Entity Type | Organization
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Legal Business Name | SPORA MEDICAL, PC.
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Dates
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Enumeration Date | 05/05/2020
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Last Update Date | 06/08/2022
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Provider Practice Location Address
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Address Line | 4445 CORPORATION LN STE 264
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City | VIRGINIA BEACH
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State | VA
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Zip | 23462-3262
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Country | US
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Telephone | 773-389-1899
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Fax |
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Provider Business Mailing Address
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Address Line | 4445 CORPORATION LN STE 264
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City | VIRGINIA BEACH
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State | VA
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Zip | 23462-3262
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Country | US
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Telephone | 773-389-1899
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Fax |
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Authorized Official
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Title or Position | COM
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Name | LAKISA DAVIS
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Credential |
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Telephone | 773-389-1899
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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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 |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 363LP2300X
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Taxonomy Name | Primary Care Nurse Practitioner
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 374J00000X
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Taxonomy Name | Doula
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number |
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License Number State |
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