Provider Demographics
NPI:1316909930
Name:DAVIS, THOMAS SANNER
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:SANNER
Last Name:DAVIS
Suffix:
Gender:M
Credentials:
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 844658
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-4658
Mailing Address - Country:US
Mailing Address - Phone:254-724-2111
Mailing Address - Fax:
Practice Address - Street 1:2401 S 31ST ST
Practice Address - Street 2:
Practice Address - City:TEMPLE
Practice Address - State:TX
Practice Address - Zip Code:76508-0001
Practice Address - Country:US
Practice Address - Phone:254-724-2111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-06
Last Update Date:2017-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX593001367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX84415UOtherBLUE SHIELD
TXP00203605OtherRR/MEDICARE
TX0025017-02Medicaid
TXP00203605OtherRR/MEDICARE
TX84415UOtherBLUE SHIELD