Provider Demographics
NPI:1578744942
Name:DAVIS, BUDDY COSTARELLA (PA-C)
Entity Type:Individual
Prefix:
First Name:BUDDY
Middle Name:COSTARELLA
Last Name:DAVIS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 E 41ST ST STE 925
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78751-4856
Mailing Address - Country:US
Mailing Address - Phone:512-978-9940
Mailing Address - Fax:
Practice Address - Street 1:1000 E 41ST ST STE 925
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78751-4856
Practice Address - Country:US
Practice Address - Phone:512-978-9940
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-14
Last Update Date:2023-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA11793363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1574874942Medicaid