Provider Demographics
NPI:1760996748
Name:DAVIS, LINCOLN WAYNE (PTA)
Entity Type:Individual
Prefix:
First Name:LINCOLN
Middle Name:WAYNE
Last Name:DAVIS
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1004 E MAIN ST STE D
Mailing Address - Street 2:
Mailing Address - City:ROCKPORT
Mailing Address - State:TX
Mailing Address - Zip Code:78382-2610
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1004 E MAIN ST STE D
Practice Address - Street 2:
Practice Address - City:ROCKPORT
Practice Address - State:TX
Practice Address - Zip Code:78382-2610
Practice Address - Country:US
Practice Address - Phone:361-727-6141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-28
Last Update Date:2017-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2082140225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant