Provider Demographics
NPI:1073370805
Name:DAVIS, TRICIA T (PA-C)
Entity Type:Individual
Prefix:
First Name:TRICIA
Middle Name:T
Last Name:DAVIS
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 1:1500 LINE AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71101-4643
Mailing Address - Country:US
Mailing Address - Phone:318-629-5555
Mailing Address - Fax:318-629-5556
Practice Address - Street 1:1500 LINE AVE STE 200
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-4643
Practice Address - Country:US
Practice Address - Phone:318-629-5555
Practice Address - Fax:318-629-5556
Is Sole Proprietor?:No
Enumeration Date:2024-02-28
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA340617363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical