Provider Demographics
NPI:1265594618
Name:DAVIS, WHITNEY DIANE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:WHITNEY
Middle Name:DIANE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:WHITNEY
Other - Middle Name:D
Other - Last Name:BARTLETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:2514 WESLEY ST STE 102
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37601-1764
Mailing Address - Country:US
Mailing Address - Phone:423-282-2700
Mailing Address - Fax:423-282-2802
Practice Address - Street 1:2514 WESLEY ST STE 102
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37601-1764
Practice Address - Country:US
Practice Address - Phone:423-282-2700
Practice Address - Fax:423-282-2802
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-14
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPA0000002497363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0010-00630OtherNC PA LICENSE INACTIVE
TN1265594618Medicaid
TN1265594618Medicaid
TN1265594618Medicare Oscar/Certification
TN1265594618Medicaid
NC0010-00630OtherNC PA LICENSE INACTIVE
TN1265594618Medicare NSC
NCQ77116Medicare UPIN