Basic Information
| Provider Information | |||||||||
| NPI: | 1497719371 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | LINDA | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 903 SUMMIT AVE | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761023421 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8178775353 | ||||||||
| FaxNumber: | 8178775357 | ||||||||
| Practice Location | |||||||||
| Address1: | 903 SUMMIT AVE | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761023421 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8178775353 | ||||||||
| FaxNumber: | 8178775357 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2006 | ||||||||
| LastUpdateDate: | 06/28/2012 | ||||||||
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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 | 363AM0700X | PA02755 | TX | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363A00000X | PA02755 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 8N2936 | 01 | TX | BCBS | OTHER | 196496702 | 05 | TX | MEDICAID | 196496703 | 05 | TX | MEDICAID | 196496701 | 05 | TX | MEDICAID | 196496704 | 05 | TX | MEDICAID | P00137420 | 01 | TX | RAILROAD MEDICARE | OTHER | 196496705 | 05 | TX | MEDICAID |