Provider Demographics
NPI:1144274515
Name:DAVIS, PATRICIA L (MD)
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:L
Last Name:DAVIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1206 W 2ND ST
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88201-2010
Mailing Address - Country:US
Mailing Address - Phone:505-623-9330
Mailing Address - Fax:505-623-5651
Practice Address - Street 1:1206 W 2ND ST
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-2010
Practice Address - Country:US
Practice Address - Phone:505-623-9330
Practice Address - Fax:505-623-5651
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-20
Last Update Date:2008-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM81-38207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM2907Medicaid
NM2907Medicaid
NM2130343Medicare PIN