Provider Demographics
NPI:1710196449
Name:DAVIS, ANDREA MARIE (MSPT)
Entity Type:Individual
Prefix:MS
First Name:ANDREA
Middle Name:MARIE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2419 HART AVE
Mailing Address - Street 2:
Mailing Address - City:DODGE CITY
Mailing Address - State:KS
Mailing Address - Zip Code:67801-2407
Mailing Address - Country:US
Mailing Address - Phone:317-413-8978
Mailing Address - Fax:
Practice Address - Street 1:1909 N 14TH AVE
Practice Address - Street 2:
Practice Address - City:DODGE CITY
Practice Address - State:KS
Practice Address - Zip Code:67801-2364
Practice Address - Country:US
Practice Address - Phone:620-338-8633
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2013-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05008025A225100000X
TX11762982251X0800X
KS11-045202251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist