Provider Demographics
NPI:1396900965
Name:DAVENPORT, DARRYL LAMONT (PA-C)
Entity type:Individual
Prefix:
First Name:DARRYL
Middle Name:LAMONT
Last Name:DAVENPORT
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3406A DALY ST
Mailing Address - Street 2:
Mailing Address - City:TWENTYNINE PALMS
Mailing Address - State:CA
Mailing Address - Zip Code:92277-9467
Mailing Address - Country:US
Mailing Address - Phone:760-830-6065
Mailing Address - Fax:
Practice Address - Street 1:200 MERCY CR
Practice Address - Street 2:
Practice Address - City:CAMP PENDLTON
Practice Address - State:CA
Practice Address - Zip Code:92055
Practice Address - Country:US
Practice Address - Phone:951-308-2200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-23
Last Update Date:2025-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA54451363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant