Provider Demographics
NPI:1205937836
Name:DAVIS, LAURIE E (MPAS, PA-C)
Entity type:Individual
Prefix:
First Name:LAURIE
Middle Name:E
Last Name:DAVIS
Suffix:
Gender:F
Credentials:MPAS, PA-C
Other - Prefix:
Other - First Name:LAURIE
Other - Middle Name:E
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MPAS PA C
Mailing Address - Street 1:2548 RIDEOUT LN
Mailing Address - Street 2:
Mailing Address - City:MURFREESBORO
Mailing Address - State:TN
Mailing Address - Zip Code:37128-7686
Mailing Address - Country:US
Mailing Address - Phone:615-410-4990
Mailing Address - Fax:615-410-4250
Practice Address - Street 1:1400 HATCHER LN
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:TN
Practice Address - Zip Code:38401-3563
Practice Address - Country:US
Practice Address - Phone:615-410-4990
Practice Address - Fax:615-410-4250
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPA1886363AM0700X, 363AM0700X
OKPA1942363A00000X
TNPA01886208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1527638Medicaid
WY313836OtherBLUE CROSS BLUE SHIELD
WY122038100Medicaid
WY122038100Medicaid
WY26272OtherWINHEALTH PARTNERS