1417914730 NPI number — PATRICK W DAVIS P.A.C.

Table of content: PATRICK W DAVIS P.A.C. (NPI 1417914730)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417914730 NPI number — PATRICK W DAVIS P.A.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DAVIS
Provider First Name:
PATRICK
Provider Middle Name:
W
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
P.A.C.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1417914730
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/22/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 752287
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAS VEGAS
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89136-2287
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
702-604-7422
Provider Business Mailing Address Fax Number:
702-549-3178

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
724 KENDALL LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOULDER CITY
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89005-1112
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
702-604-7422
Provider Business Practice Location Address Fax Number:
702-549-3178
Provider Enumeration Date:
04/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363AS0400X , with the licence number:  PA823 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: PA823 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: PA823 . This is a "NSBME" identifier , issued by the state of ( NV ) . This identifiers is of the category "OTHER".
  • Identifier: 100502933 , issued by the state of ( NV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 850273 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00206370 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( NV ) . This identifiers is of the category "OTHER".
  • Identifier: CC535Y . This is a "MEDICARE PTAN" identifier , issued by the state of ( NV ) . This identifiers is of the category "OTHER".




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