Provider Demographics
NPI:1033998810
Name:DAVIS, EDGAR
Entity type:Individual
Prefix:
First Name:EDGAR
Middle Name:
Last Name:DAVIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7918 WILLOWS POND CT
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28277-8408
Mailing Address - Country:US
Mailing Address - Phone:704-954-4815
Mailing Address - Fax:
Practice Address - Street 1:4121 LITTLE SAVANNAH RD
Practice Address - Street 2:
Practice Address - City:CULLOWHEE
Practice Address - State:NC
Practice Address - Zip Code:28723
Practice Address - Country:US
Practice Address - Phone:704-954-4815
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-21
Last Update Date:2024-08-15
Deactivation Date:2024-06-05
Deactivation Code:
Reactivation Date:2024-08-01
Provider Licenses
StateLicense IDTaxonomies
225100000X, 390200000X
NCLAT-58092255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer