MEDICARE: MR. BRENT MICHAEL DAVIS PA-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	APA2052	OK

General Provider Information

NPI Number	:	1568731628
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. BRENT MICHAEL DAVIS PA-C

Provider Business Mailing Address
First Line	:	34 SW 89TH ST
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73139-8510
Country	:	US
Telephone Number	:	405-488-0750
Fax Number	:	405-488-0761

Provider Business Practice Location Address
First Line	:	34 SW 89TH ST
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73139-8510
Country	:	US
Telephone Number	:	405-488-0750
Fax Number	:	405-488-0761

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

Provider Enumeration Date	:	12/19/2011
Last Update Date	:	12/19/2011

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