Provider Demographics
NPI:1629538822
Name:DAVIS, TREVOR LAWTON (PA)
Entity Type:Individual
Prefix:
First Name:TREVOR
Middle Name:LAWTON
Last Name:DAVIS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3301 N OAK STREET EXT
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31605
Mailing Address - Country:US
Mailing Address - Phone:229-242-6061
Mailing Address - Fax:229-242-6151
Practice Address - Street 1:3301 N OAK STREET EXT
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31605
Practice Address - Country:US
Practice Address - Phone:229-242-6061
Practice Address - Fax:229-242-6151
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-22
Last Update Date:2019-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA9150363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA051253600OtherDRIVERS LICENSE