Basic Information
| Provider Information | |||||||||
| NPI: | 1396900965 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVENPORT | ||||||||
| FirstName: | DARRYL | ||||||||
| MiddleName: | LAMONT | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3406A DALY ST | ||||||||
| Address2: | |||||||||
| City: | TWENTYNINE PALMS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922779467 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7608306065 | ||||||||
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| Practice Location | |||||||||
| Address1: | 27168 NEWPORT RD STE 1 | ||||||||
| Address2: | |||||||||
| City: | MENIFEE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925847383 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9512463033 | ||||||||
| FaxNumber: | 9512467373 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/23/2008 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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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 | 363A00000X | 54451 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.