Provider Demographics
NPI:1023382009
Name:DAVENPORT, NICOLE BAUTISTA (PA-C)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:BAUTISTA
Last Name:DAVENPORT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6560 FANNIN ST STE 1842
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-2715
Mailing Address - Country:US
Mailing Address - Phone:713-790-2089
Mailing Address - Fax:
Practice Address - Street 1:6560 FANNIN ST STE 1842
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-2715
Practice Address - Country:US
Practice Address - Phone:713-790-2089
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-08
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA07728363A00000X
TXPA00000363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX296297903Medicaid