MEDICARE: DAVIS ISON

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	390200000X	Student in an Organized Health Care Education/Training Program
2	2255A2300X	Athletic Trainer

General Provider Information

NPI Number	:	1881177731
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DAVIS ISON

Provider Business Mailing Address
First Line	:	5980 SEVILLE DR
Second Line	:
City	:	LAKE PARK
State	:	GA
Zip	:	31636-4934
Country	:	US
Telephone Number	:	229-251-4222
Fax Number	:

Provider Business Practice Location Address
First Line	:	5980 SEVILLE DR
Second Line	:
City	:	LAKE PARK
State	:	GA
Zip	:	31636-4934
Country	:	US
Telephone Number	:	229-251-4222
Fax Number	:

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

Provider Enumeration Date	:	09/06/2018
Last Update Date	:	09/06/2018

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Directions to “ DAVIS ISON ” Practice Location

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