Provider Demographics
NPI:1699774539
Name:DAVIS, DEMETRIA LEONARD (PA-C)
Entity type:Individual
Prefix:
First Name:DEMETRIA
Middle Name:LEONARD
Last Name:DAVIS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6100 PRIMACY PKWY
Mailing Address - Street 2:SUITE 112
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38119-0705
Mailing Address - Country:US
Mailing Address - Phone:901-682-5335
Mailing Address - Fax:901-682-5440
Practice Address - Street 1:6100 PRIMACY PKWY
Practice Address - Street 2:SUITE 112
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-0705
Practice Address - Country:US
Practice Address - Phone:901-682-5335
Practice Address - Fax:901-682-5440
Is Sole Proprietor?:No
Enumeration Date:2005-07-21
Last Update Date:2011-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPA1876363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1522983Medicaid
NCQ32538Medicare UPIN
NC2762421AMedicare ID - Type UnspecifiedLUMBERTON HEALTH CENTER
TN1522983Medicaid
TN103I972545Medicare PIN
NC2762421CMedicare ID - Type UnspecifiedSOUTH ROBESON MEDICAL CTR
NC2762421BMedicare ID - Type UnspecifiedMAXTON MEDICAL CENTER