Basic Information
| Provider Information | |||||||||
| NPI: | 1083609200 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | SCOTT | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 105 W STONE DR | ||||||||
| Address2: | SUITE 6A | ||||||||
| City: | KINGSPORT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376603365 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234087220 | ||||||||
| FaxNumber: | 4234087405 | ||||||||
| Practice Location | |||||||||
| Address1: | 130 W RAVINE RD | ||||||||
| Address2: | |||||||||
| City: | KINGSPORT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376603837 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232244000 | ||||||||
| FaxNumber: | 4232244746 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2005 | ||||||||
| LastUpdateDate: | 05/08/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 10774 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 100047850 | 05 | TN | MEDICAID | 4101127 | 01 | TN | BLUE SHIELD | OTHER | 74009465 | 05 | KY | MEDICAID | 00013859 | 01 | NHC CARE ADMINISTRATORS | OTHER | 010137276 | 05 | VA | MEDICAID | 175337 | 01 | ANTHEM BCBS | OTHER | TN0100 | 01 | JOHN DEERE | OTHER | 3634345 | 05 | TN | MEDICAID |