Basic Information
| Provider Information | |||||||||
| NPI: | 1326041831 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | G. | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | II | ||||||||
| Credential: | RN,CS,FNP-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 11768 MALLARD DR | ||||||||
| Address2: | |||||||||
| City: | NEOSHO | ||||||||
| State: | MO | ||||||||
| PostalCode: | 648508585 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4174510282 | ||||||||
| FaxNumber: | 4174516277 | ||||||||
| Practice Location | |||||||||
| Address1: | 1706 SE WALTON BLVD | ||||||||
| Address2: | |||||||||
| City: | BENTONVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727123200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4794640400 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2005 | ||||||||
| LastUpdateDate: | 09/07/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | RN089423 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | RN089423 | 01 | MO | RN LICENSE MISSOURI | OTHER | 425287109 | 05 | MO | MEDICAID |