Provider Demographics
NPI:1134318710
Name:DAVIS, VANIESA M (PA)
Entity Type:Individual
Prefix:
First Name:VANIESA
Middle Name:M
Last Name:DAVIS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:VANIESA
Other - Middle Name:J
Other - Last Name:MASON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11914 ASTORIA BLVD
Mailing Address - Street 2:#300
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77089-6064
Mailing Address - Country:US
Mailing Address - Phone:281-922-5099
Mailing Address - Fax:281-922-5490
Practice Address - Street 1:11914 ASTORIA BLVD
Practice Address - Street 2:#300
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77089-6064
Practice Address - Country:US
Practice Address - Phone:281-922-5099
Practice Address - Fax:281-922-5490
Is Sole Proprietor?:No
Enumeration Date:2007-10-18
Last Update Date:2008-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA02724363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8K7224Medicare PIN