MEDICARE: KRISTINA ANDERSON DAVIS

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	0110006683	VA
2	363A00000X	Physician Assistant	0010-12774	NC

General Provider Information

NPI Number	:	1932670163
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRISTINA ANDERSON DAVIS

Provider Business Mailing Address
First Line	:	PO BOX 601843
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28260-1843
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1530 PROVIDENCE RD S
Second Line	:
City	:	WAXHAW
State	:	NC
Zip	:	28173-8313
Country	:	US
Telephone Number	:	704-627-8365
Fax Number	:	704-627-8366

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

Provider Enumeration Date	:	12/16/2018
Last Update Date	:	04/05/2023

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