Basic Information
| Provider Information | |||||||||
| NPI: | 1083647960 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | CLIFTON | ||||||||
| MiddleName: | H | ||||||||
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| Credential: | P.A.-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3688 VETERANS MEMORIAL DR | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | HATTIESBURG | ||||||||
| State: | MS | ||||||||
| PostalCode: | 394018246 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6015547400 | ||||||||
| FaxNumber: | 6015547488 | ||||||||
| Practice Location | |||||||||
| Address1: | 3688 VETERANS MEMORIAL DR | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | HATTIESBURG | ||||||||
| State: | MS | ||||||||
| PostalCode: | 394018246 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6015547400 | ||||||||
| FaxNumber: | 6015547488 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2006 | ||||||||
| LastUpdateDate: | 12/23/2009 | ||||||||
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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 | 363AM0700X | PA021 | MS | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 01802226 | 05 | MS | MEDICAID |