Provider Demographics
NPI:1053705871
Name:DAVIS, MARK EDWARD (CNP)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:EDWARD
Last Name:DAVIS
Suffix:
Gender:M
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Mailing Address - Street 1:200 CORPORATE BLVD
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-3870
Mailing Address - Country:US
Mailing Address - Phone:800-893-9698
Mailing Address - Fax:
Practice Address - Street 1:801 5TH ST
Practice Address - Street 2:
Practice Address - City:SIOUX CITY
Practice Address - State:IA
Practice Address - Zip Code:51101
Practice Address - Country:US
Practice Address - Phone:712-279-2010
Practice Address - Fax:712-279-2034
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-19
Last Update Date:2019-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF343808-1363L00000X
VA0024176683363L00000X
COC-APN.0000471363L00000X
NMCNP-02625363L00000X
IAA155082363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner