Basic Information
Provider Information | |||||||||
NPI: | 1366784167 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MADE LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | LAWRENCE A. DAVIS | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1882 E 104TH AVE UNIT 936 | ||||||||
Address2: |   | ||||||||
City: | THORNTON | ||||||||
State: | CO | ||||||||
PostalCode: | 802334336 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7203633145 | ||||||||
FaxNumber: | 7203816313 | ||||||||
Practice Location | |||||||||
Address1: | 1882 E 104TH AVE UNIT 936 | ||||||||
Address2: |   | ||||||||
City: | THORNTON | ||||||||
State: | CO | ||||||||
PostalCode: | 802334336 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7203633145 | ||||||||
FaxNumber: | 7203816313 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/20/2013 | ||||||||
LastUpdateDate: | 03/20/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | DAVIS | ||||||||
AuthorizedOfficialFirstName: | LAWRENCE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CERT. SURG FIRST ASSIST | ||||||||
AuthorizedOfficialTelephone: | 7203633145 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | CSFA | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | 1520 | CO | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
ID | Type | State | Issuer | Description | 010801006 | 01 | CO | COLORADO DRIVERS LICENSE | OTHER |