Provider Demographics
NPI:1811300718
Name:DAVIS, JUSTIN N (CRNA)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:N
Last Name:DAVIS
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2610 S ROCKINGCHAIR RD
Mailing Address - Street 2:
Mailing Address - City:PARAGOULD
Mailing Address - State:AR
Mailing Address - Zip Code:72450-9609
Mailing Address - Country:US
Mailing Address - Phone:870-240-5877
Mailing Address - Fax:
Practice Address - Street 1:2610 S ROCKINGCHAIR RD
Practice Address - Street 2:
Practice Address - City:PARAGOULD
Practice Address - State:AR
Practice Address - Zip Code:72450-9609
Practice Address - Country:US
Practice Address - Phone:870-240-5877
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-09
Last Update Date:2017-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC003044367500000X
IL041.420223367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR206712001Medicaid