Provider Demographics
NPI:1497719371
Name:DAVIS, LINDA (PA)
Entity Type:Individual
Prefix:
First Name:LINDA
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 1:903 SUMMIT AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76102-3421
Mailing Address - Country:US
Mailing Address - Phone:817-877-5353
Mailing Address - Fax:817-877-5357
Practice Address - Street 1:903 SUMMIT AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76102-3421
Practice Address - Country:US
Practice Address - Phone:817-877-5353
Practice Address - Fax:817-877-5357
Is Sole Proprietor?:No
Enumeration Date:2006-04-17
Last Update Date:2012-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA02755363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8N2936OtherBCBS
TX196496702Medicaid
TX196496703Medicaid
TX196496701Medicaid
TX196496704Medicaid
TXP00137420OtherRAILROAD MEDICARE
TX196496705Medicaid
TXP00137420OtherRAILROAD MEDICARE
TX8N2936OtherBCBS
TX196496705Medicaid
TXTXB108652Medicare PIN
TXTXB108650Medicare PIN
TX8L9464Medicare PIN