Provider Demographics
NPI:1053824102
Name:PETERS, TRAVIS JOHN (NA)
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:JOHN
Last Name:PETERS
Suffix:
Gender:M
Credentials:NA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2634 S 72ND ST
Mailing Address - Street 2:
Mailing Address - City:WEST ALLIS
Mailing Address - State:WI
Mailing Address - Zip Code:53219-2533
Mailing Address - Country:US
Mailing Address - Phone:414-531-3722
Mailing Address - Fax:
Practice Address - Street 1:1501 AIRPORT RD
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-2461
Practice Address - Country:US
Practice Address - Phone:262-548-7986
Practice Address - Fax:262-970-4799
Is Sole Proprietor?:No
Enumeration Date:2017-11-12
Last Update Date:2017-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI347962376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide