Provider Demographics
NPI:1235172917
Name:DAVIS, MICHAEL SHANE SR (APRN)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:SHANE
Last Name:DAVIS
Suffix:SR
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5130 SUNFOREST DR STE 300
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33634-6327
Mailing Address - Country:US
Mailing Address - Phone:727-824-0780
Mailing Address - Fax:813-514-8891
Practice Address - Street 1:5130 SUNFOREST DR STE 300
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33634-6327
Practice Address - Country:US
Practice Address - Phone:727-824-0780
Practice Address - Fax:813-514-8891
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2021-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP2243822363L00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001486300Medicaid
FL001486300Medicaid