Provider Demographics
NPI:1285722991
Name:DAVIS, ANTHONY B SR (PA)
Entity type:Individual
Prefix:
First Name:ANTHONY
Middle Name:B
Last Name:DAVIS
Suffix:SR
Gender:M
Credentials:PA
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 2876
Mailing Address - Street 2:
Mailing Address - City:MOULTRIE
Mailing Address - State:GA
Mailing Address - Zip Code:31776-2876
Mailing Address - Country:US
Mailing Address - Phone:229-891-9148
Mailing Address - Fax:
Practice Address - Street 1:16 LIVE OAK CT
Practice Address - Street 2:
Practice Address - City:MOULTRIE
Practice Address - State:GA
Practice Address - Zip Code:31768
Practice Address - Country:US
Practice Address - Phone:229-891-9148
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2024-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA002208363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAS41826Medicare UPIN
GA97BB7RKMedicare ID - Type Unspecified