Provider Demographics
NPI:1659592244
Name:DAVIS, BERRIAN L (PA-AA)
Entity Type:Individual
Prefix:
First Name:BERRIAN
Middle Name:L
Last Name:DAVIS
Suffix:
Gender:M
Credentials:PA-AA
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 551420
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33355-1420
Mailing Address - Country:US
Mailing Address - Phone:800-243-3839
Mailing Address - Fax:855-851-4405
Practice Address - Street 1:777 HEMLOCK ST
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-2102
Practice Address - Country:US
Practice Address - Phone:866-507-5244
Practice Address - Fax:855-851-4405
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2014-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003155367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA100002735AMedicaid
GA344299OtherWELLCARE CMO - MCCG
GA100002735AOtherPEACHSTATE CMO - MCCG
S88929Medicare UPIN
GAS88929Medicare UPIN
GA344299OtherWELLCARE CMO - MCCG