Provider Demographics
NPI:1013386507
Name:DAVIS, KURVIS ANTIONE
Entity Type:Individual
Prefix:
First Name:KURVIS
Middle Name:ANTIONE
Last Name:DAVIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:367 CARROLLTON AVE
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-3205
Mailing Address - Country:US
Mailing Address - Phone:318-573-0604
Mailing Address - Fax:
Practice Address - Street 1:367 CARROLLTON AVE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-3205
Practice Address - Country:US
Practice Address - Phone:318-573-0604
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-15
Last Update Date:2016-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP08517367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered