Provider Demographics
NPI:1013549880
Name:KOEHN, TRAVIS LEE
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:LEE
Last Name:KOEHN
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 1:105 SADDLE TRAIL DR
Mailing Address - Street 2:
Mailing Address - City:LUFKIN
Mailing Address - State:TX
Mailing Address - Zip Code:75904-8812
Mailing Address - Country:US
Mailing Address - Phone:402-750-9995
Mailing Address - Fax:
Practice Address - Street 1:105 SADDLE TRAIL DR
Practice Address - Street 2:
Practice Address - City:LUFKIN
Practice Address - State:TX
Practice Address - Zip Code:75904-7590
Practice Address - Country:US
Practice Address - Phone:402-750-9995
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-10
Last Update Date:2020-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX020809Medicaid