Provider Demographics
NPI:1043755283
Name:FETCHKO, TRAVIS
Entity Type:Individual
Prefix:MR
First Name:TRAVIS
Middle Name:
Last Name:FETCHKO
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 1:3602 JEFFERSON COMMONS DR
Mailing Address - Street 2:APT. 201B
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33613-6432
Mailing Address - Country:US
Mailing Address - Phone:706-254-6204
Mailing Address - Fax:
Practice Address - Street 1:3602 JEFFERSON COMMONS DR
Practice Address - Street 2:APT. 201B
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33613-6432
Practice Address - Country:US
Practice Address - Phone:706-254-6204
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-26
Last Update Date:2016-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer