Provider Demographics
NPI:1881340081
Name:DAVIS, BLAINE SCOTT (PTA)
Entity type:Individual
Prefix:
First Name:BLAINE
Middle Name:SCOTT
Last Name:DAVIS
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:216 HILLVALE ST
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63701-9571
Mailing Address - Country:US
Mailing Address - Phone:619-655-0289
Mailing Address - Fax:
Practice Address - Street 1:216 HILLVALE ST
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63701-9571
Practice Address - Country:US
Practice Address - Phone:619-655-0289
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-25
Last Update Date:2022-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016037346225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
2016037346OtherSTATE OF MISSOURI