Provider Demographics
NPI:1225593247
Name:DAVIS, COLETON SHANE
Entity Type:Individual
Prefix:
First Name:COLETON
Middle Name:SHANE
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 1:2510 PINE ST # 4303
Mailing Address - Street 2:
Mailing Address - City:ABILENE
Mailing Address - State:TX
Mailing Address - Zip Code:79601-1508
Mailing Address - Country:US
Mailing Address - Phone:903-494-1833
Mailing Address - Fax:
Practice Address - Street 1:2200 HICKORY ST
Practice Address - Street 2:
Practice Address - City:ABILENE
Practice Address - State:TX
Practice Address - Zip Code:79601-2345
Practice Address - Country:US
Practice Address - Phone:903-494-1833
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-04
Last Update Date:2019-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program