Provider Demographics
NPI:1326153198
Name:DAVIS, TIMOTHY C (RN,PNP)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:C
Last Name:DAVIS
Suffix:
Gender:M
Credentials:RN,PNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2330 BARBERRY DR
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75211-1805
Mailing Address - Country:US
Mailing Address - Phone:214-529-1859
Mailing Address - Fax:
Practice Address - Street 1:104 S PARK DR
Practice Address - Street 2:
Practice Address - City:BROWNWOOD
Practice Address - State:TX
Practice Address - Zip Code:76801-5918
Practice Address - Country:US
Practice Address - Phone:325-646-0704
Practice Address - Fax:325-646-1513
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2012-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX582080363LP0200X, 363LP0222X, 363LN0000X, 363LN0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No363LP0222XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics, Critical Care
No363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal
No363LN0005XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal, Critical Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1742694Medicaid