Provider Demographics
NPI:1396947198
Name:DAVIS, STEPHEN KEITH (PA)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:KEITH
Last Name:DAVIS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:57 ADLER CIR
Mailing Address - Street 2:
Mailing Address - City:GALVESTON
Mailing Address - State:TX
Mailing Address - Zip Code:77551-5829
Mailing Address - Country:US
Mailing Address - Phone:409-740-0886
Mailing Address - Fax:
Practice Address - Street 1:1400 GEORGE DIETER DR
Practice Address - Street 2:SUITE 100
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79936-7601
Practice Address - Country:US
Practice Address - Phone:915-921-7600
Practice Address - Fax:915-857-4390
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA01783363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXQ17077Medicare UPIN
TX8B9028Medicare ID - Type Unspecified