Provider Demographics
NPI:1770586570
Name:DAVIS, DEBRA D (PA)
Entity type:Individual
Prefix:
First Name:DEBRA
Middle Name:D
Last Name:DAVIS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:DEBRA
Other - Middle Name:D
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:12526 E CENTRAL AVE APT 1023
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67206-2853
Mailing Address - Country:US
Mailing Address - Phone:316-655-9126
Mailing Address - Fax:
Practice Address - Street 1:7111 E 21ST ST N STE A
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67206-1078
Practice Address - Country:US
Practice Address - Phone:316-684-2851
Practice Address - Fax:316-683-5239
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2021-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1500252363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100343060BMedicaid
KSQ10930Medicare UPIN
KS100343060BMedicaid