Provider Demographics
NPI:1417555152
Name:LIA DAVALOS PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:LIA DAVALOS PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:LIA
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVALOS
Authorized Official - Suffix:
Authorized Official - Credentials:AGACNP-BC
Authorized Official - Phone:915-615-7150
Mailing Address - Street 1:10470 VISTA DEL SOL DR STE 102
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79925-7928
Mailing Address - Country:US
Mailing Address - Phone:915-615-7150
Mailing Address - Fax:915-207-2143
Practice Address - Street 1:10470 VISTA DEL SOL DR
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79925-7948
Practice Address - Country:US
Practice Address - Phone:915-615-7150
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-14
Last Update Date:2021-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty