Provider Demographics
NPI:1780691063
Name:DAVIS, LAURA ANN (PA)
Entity type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:ANN
Last Name:DAVIS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MISS
Other - First Name:LAURA
Other - Middle Name:ANN
Other - Last Name:NIZER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 911230
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75391-1230
Mailing Address - Country:US
Mailing Address - Phone:972-997-8000
Mailing Address - Fax:512-834-8676
Practice Address - Street 1:12221 RENFERT WAY STE 300
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78758-5453
Practice Address - Country:US
Practice Address - Phone:512-873-8900
Practice Address - Fax:512-834-8676
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2019-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA04491363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8N8469OtherBCBS OF TEXAS
TX190535803Medicaid
TX190535804Medicaid
TX190535804Medicaid
TX468194YK4EMedicare PIN
TX190535801Medicaid