Provider Demographics
NPI:1760426449
Name:DAVIS, JOHN PAUL (NP)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:PAUL
Last Name:DAVIS
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:719 CEDAR VIEW DR
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:CA
Mailing Address - Zip Code:92223-6417
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:HI-DESERT MEDICAL CENTER
Practice Address - Street 2:6601 WHITE FEATHER ROAD
Practice Address - City:JOSHUA TREE
Practice Address - State:CA
Practice Address - Zip Code:92252
Practice Address - Country:US
Practice Address - Phone:760-366-3711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2018-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15101207P00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARN85634Medicaid
CAZZZ016242Medicare ID - Type Unspecified
CARN85634Medicaid
CACC327ZMedicare PIN