Provider Demographics
NPI:1740656578
Name:DAVIS, DEBRA DIANE
Entity type:Individual
Prefix:MS
First Name:DEBRA
Middle Name:DIANE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11214 INDIAN CYN
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78252-2783
Mailing Address - Country:US
Mailing Address - Phone:210-763-4464
Mailing Address - Fax:210-254-9531
Practice Address - Street 1:11214 INDIAN CYN
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78252-2783
Practice Address - Country:US
Practice Address - Phone:210-763-4464
Practice Address - Fax:210-254-9531
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-17
Last Update Date:2015-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX16677081343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXTEXASMedicaid