Provider Demographics
NPI: | 1932198124 |
---|---|
Name: | DAVIS, BRIAN E (APRN) |
Entity Type: | Individual |
Prefix: | |
First Name: | BRIAN |
Middle Name: | E |
Last Name: | DAVIS |
Suffix: | |
Gender: | M |
Credentials: | APRN |
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 2379 |
Mailing Address - Street 2: | |
Mailing Address - City: | ASHLAND |
Mailing Address - State: | KY |
Mailing Address - Zip Code: | 41105-2379 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 606-408-6200 |
Mailing Address - Fax: | 606-408-6612 |
Practice Address - Street 1: | 613 23RD ST STE 230 |
Practice Address - Street 2: | |
Practice Address - City: | ASHLAND |
Practice Address - State: | KY |
Practice Address - Zip Code: | 41101-2868 |
Practice Address - Country: | US |
Practice Address - Phone: | 606-324-4745 |
Practice Address - Fax: | 606-324-4941 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2005-10-19 |
Last Update Date: | 2019-02-21 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
KY | 3004151 | 363LF0000X, 363L00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 363L00000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | |
No | 363LF0000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
KY | 78011319 | Medicaid | |
P99166 | Medicare UPIN | ||
KY | K118401 | Medicare PIN |