Provider Demographics
NPI:1609820588
Name:DAVIS, DAVID R (CRNA)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:R
Last Name:DAVIS
Suffix:
Gender:M
Credentials:CRNA
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 4860
Mailing Address - Street 2:
Mailing Address - City:MURRELLS INLET
Mailing Address - State:SC
Mailing Address - Zip Code:29576-2698
Mailing Address - Country:US
Mailing Address - Phone:843-651-2624
Mailing Address - Fax:843-491-4023
Practice Address - Street 1:1021 MEDICAL CIR
Practice Address - Street 2:#100
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29572-4608
Practice Address - Country:US
Practice Address - Phone:843-692-1062
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2016-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2255367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCAN0581Medicaid
SCQ291308431Medicare ID - Type Unspecified
SCQ291308721Medicare PIN