Provider Demographics
NPI:1548928484
Name:DAVIS, MIKE (RN, BSN)
Entity type:Individual
Prefix:
First Name:MIKE
Middle Name:
Last Name:DAVIS
Suffix:
Gender:M
Credentials:RN, BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2906 MAGNOLIA ST
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94608-4414
Mailing Address - Country:US
Mailing Address - Phone:415-308-8990
Mailing Address - Fax:
Practice Address - Street 1:2633 E 27TH ST
Practice Address - Street 2:GLADMAN MHRC
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94601
Practice Address - Country:US
Practice Address - Phone:510-536-8111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-07
Last Update Date:2021-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95127365163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse