Basic Information
| Provider Information | |||||||||
| NPI: | 1457350431 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 PARK FORTY PLZ | ||||||||
| Address2: | SUITE #550 | ||||||||
| City: | DURHAM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 277135249 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002914020 | ||||||||
| FaxNumber: | 9563678474 | ||||||||
| Practice Location | |||||||||
| Address1: | 7400 BARLITE BLVD | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782241308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2109213599 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2005 | ||||||||
| LastUpdateDate: | 08/17/2016 | ||||||||
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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 | 363L00000X | 632009 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 8N7439 | 01 | TX | BCBS | OTHER | 172991501 | 05 | TX | MEDICAID |