Provider Demographics
NPI:1033856265
Name:WHITE, TRAVIS MICHAEL (LAT, ATC)
Entity Type:Individual
Prefix:MR
First Name:TRAVIS
Middle Name:MICHAEL
Last Name:WHITE
Suffix:
Gender:M
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10697 W CENTENNIAL PKWY APT 2076
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89166-1510
Mailing Address - Country:US
Mailing Address - Phone:702-501-2740
Mailing Address - Fax:
Practice Address - Street 1:5302 GOLDFIELD ST
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89031-2934
Practice Address - Country:US
Practice Address - Phone:702-501-2740
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-18
Last Update Date:2022-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV05063012255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer