Provider Demographics
NPI:1003265117
Name:CRUZ, TRAVIS WILLIAM
Entity Type:Individual
Prefix:MR
First Name:TRAVIS
Middle Name:WILLIAM
Last Name:CRUZ
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 1:9525 LOS AMIGOS CT
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92508-6830
Mailing Address - Country:US
Mailing Address - Phone:951-250-1475
Mailing Address - Fax:
Practice Address - Street 1:9525 LOS AMIGOS COURT
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92508
Practice Address - Country:US
Practice Address - Phone:951-250-1475
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-09
Last Update Date:2016-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical