MEDICARE: NICOLE BAUTISTA DAVENPORT P.A.-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	PA07728	TX
2	363AS0400X	Surgical Physician Assistant	PA00000	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1023382009
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE BAUTISTA DAVENPORT P.A.-C

Provider Business Mailing Address
First Line	:	6560 FANNIN ST STE 1842
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77030-2715
Country	:	US
Telephone Number	:	713-790-2089
Fax Number	:

Provider Business Practice Location Address
First Line	:	6560 FANNIN ST STE 1842
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77030-2715
Country	:	US
Telephone Number	:	713-790-2089
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/08/2012
Last Update Date	:	03/17/2018

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