Provider Demographics
NPI:1083612675
Name:DAVIS, CAROL (CRNA)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 64382
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-4382
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:900 CATON AVE
Practice Address - Street 2:ANESTHESIA DEPARTMENT
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21229-5201
Practice Address - Country:US
Practice Address - Phone:410-368-3045
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-08
Last Update Date:2016-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR096571367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD778300100Medicaid
MD778300100Medicaid