1922601921 NPI number — ADAM TYLER DAVENPORT AGACNP-BC

Table of content: ADAM TYLER DAVENPORT AGACNP-BC (NPI 1922601921)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922601921 NPI number — ADAM TYLER DAVENPORT AGACNP-BC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DAVENPORT
Provider First Name:
ADAM
Provider Middle Name:
TYLER
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
AGACNP-BC
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:
1922601921
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/20/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3930 MONTCLAIR RD APT E
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOUNTAIN BRK
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35213-2424
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
334-398-1534
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3368 HIGHWAY 280 STE 130
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALEX CITY
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35010-3375
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
256-234-2644
Provider Business Practice Location Address Fax Number:
256-234-2704
Provider Enumeration Date:
11/20/2020

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: 363LA2100X , with the licence number:  1-148279 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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