Provider Demographics
NPI:1265121750
Name:DAVIS, WILLIE ANTHONEY JR
Entity type:Individual
Prefix:
First Name:WILLIE
Middle Name:ANTHONEY
Last Name:DAVIS
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23430 CALISTOGA PL
Mailing Address - Street 2:
Mailing Address - City:RAMONA
Mailing Address - State:CA
Mailing Address - Zip Code:92065-4309
Mailing Address - Country:US
Mailing Address - Phone:209-769-5243
Mailing Address - Fax:
Practice Address - Street 1:23430 CALISTOGA PL
Practice Address - Street 2:
Practice Address - City:RAMONA
Practice Address - State:CA
Practice Address - Zip Code:92065-4309
Practice Address - Country:US
Practice Address - Phone:209-769-5243
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-02
Last Update Date:2023-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD3692300OtherDRIVER LICENSE