Basic Information
| Provider Information | |||||||||
| NPI: | 1699003210 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | DAMON | ||||||||
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| Credential: | AHCNS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1269 COUNTY ROAD 468 | ||||||||
| Address2: | |||||||||
| City: | POPLAR BLUFF | ||||||||
| State: | MO | ||||||||
| PostalCode: | 639012989 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5737782888 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3100 WARRIOR LN | ||||||||
| Address2: | |||||||||
| City: | POPLAR BLUFF | ||||||||
| State: | MO | ||||||||
| PostalCode: | 639018686 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5737279311 | ||||||||
| FaxNumber: | 5737850182 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/19/2009 | ||||||||
| LastUpdateDate: | 07/31/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/31/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 364SA2200X | 2009033936 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Adult Health |
No ID Information.