Provider Demographics
NPI:1750739405
Name:DAVIS, KEVIN LEE (PA-C)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:LEE
Last Name:DAVIS
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:PO BOX 1500
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:TX
Mailing Address - Zip Code:76426-1500
Mailing Address - Country:US
Mailing Address - Phone:940-255-6552
Mailing Address - Fax:940-202-7058
Practice Address - Street 1:1306 13TH ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:TX
Practice Address - Zip Code:76426-2454
Practice Address - Country:US
Practice Address - Phone:940-648-1402
Practice Address - Fax:940-648-1400
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-02
Last Update Date:2024-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA10658363AM0700X, 207Q00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty