Basic Information
| Provider Information | |||||||||
| NPI: | 1134668379 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | RYAN | ||||||||
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| Credential: | DNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 900 ELKRIDGE LANDING RD FL 2 | ||||||||
| Address2: | |||||||||
| City: | LINTHICUM | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210902924 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4434625010 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1975 TOWN CENTER BLVD | ||||||||
| Address2: | |||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379226638 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8655463998 | ||||||||
| FaxNumber: | 8655461123 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2017 | ||||||||
| LastUpdateDate: | 10/05/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | AC002679 | MD | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics | 363LP0200X | 22306 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | Q018806 | 05 | TN | MEDICAID |