Provider Demographics
NPI:1558389817
Name:DAVIS, LOGOI B (PA)
Entity Type:Individual
Prefix:
First Name:LOGOI
Middle Name:B
Last Name:DAVIS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3945 LAWRENCEVILLE HWY NW
Mailing Address - Street 2:
Mailing Address - City:LILBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30047-2817
Mailing Address - Country:US
Mailing Address - Phone:678-380-8353
Mailing Address - Fax:378-380-8388
Practice Address - Street 1:715 QUEEN CITY PKWY
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-4348
Practice Address - Country:US
Practice Address - Phone:770-531-5115
Practice Address - Fax:770-531-5116
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2014-08-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA3158363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA387169911CMedicaid
GA387169911DMedicaid
GA387169911GMedicaid
GA387169911FMedicaid
GA387169911HMedicaid
GA387169911EMedicaid
GA387169911DMedicaid