Basic Information
| Provider Information | |||||||||
| NPI: | 1750368361 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | LACRESA | ||||||||
| MiddleName: | B. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7703 FLOYD CURL | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782293901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2102571400 | ||||||||
| FaxNumber: | 2102571428 | ||||||||
| Practice Location | |||||||||
| Address1: | 7703 FLOYD CURL | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782293901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2102571400 | ||||||||
| FaxNumber: | 2102571428 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/23/2005 | ||||||||
| LastUpdateDate: | 07/06/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 567944 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 134778314 | 01 | TX | CSHCN | OTHER | 134778316 | 05 | TX | MEDICAID | 134778315 | 05 | TX | MEDICAID |