Provider Demographics
NPI:1376618736
Name:DAVIS, MARTHA (PA)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 488
Mailing Address - Street 2:
Mailing Address - City:SIMONTON
Mailing Address - State:TX
Mailing Address - Zip Code:77476-0488
Mailing Address - Country:US
Mailing Address - Phone:713-582-0217
Mailing Address - Fax:
Practice Address - Street 1:538 BROADWAY
Practice Address - Street 2:
Practice Address - City:WINNIE
Practice Address - State:TX
Practice Address - Zip Code:77665-7600
Practice Address - Country:US
Practice Address - Phone:409-296-6000
Practice Address - Fax:409-296-6326
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2020-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA00635363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant