Provider Demographics
NPI:1346804762
Name:DAVIS, RAYMOND LEON JR (PTA)
Entity Type:Individual
Prefix:
First Name:RAYMOND
Middle Name:LEON
Last Name:DAVIS
Suffix:JR
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 NORBERT CIR
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72034-2010
Mailing Address - Country:US
Mailing Address - Phone:501-352-0256
Mailing Address - Fax:
Practice Address - Street 1:1300 NORBERT CIR
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72034-2010
Practice Address - Country:US
Practice Address - Phone:501-352-0256
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-01
Last Update Date:2019-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR4215225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant