Provider Demographics
NPI:1003186693
Name:BURT, TRAVIS DAVID (LMP)
Entity Type:Individual
Prefix:MR
First Name:TRAVIS
Middle Name:DAVID
Last Name:BURT
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1838 PORTER ST
Mailing Address - Street 2:
Mailing Address - City:ENUMCLAW
Mailing Address - State:WA
Mailing Address - Zip Code:98022
Mailing Address - Country:US
Mailing Address - Phone:206-979-3160
Mailing Address - Fax:
Practice Address - Street 1:1838 PORTER ST
Practice Address - Street 2:
Practice Address - City:ENUMCLAW
Practice Address - State:WA
Practice Address - Zip Code:98022
Practice Address - Country:US
Practice Address - Phone:206-979-3160
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-12
Last Update Date:2012-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60259571174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist