Provider Demographics
NPI:1083084875
Name:NULL, TRAVIS JEWELL (FNP)
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:JEWELL
Last Name:NULL
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1607 E US HIGHWAY 136
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:MO
Mailing Address - Zip Code:64402-8223
Mailing Address - Country:US
Mailing Address - Phone:660-726-3333
Mailing Address - Fax:660-726-3232
Practice Address - Street 1:1607 E US HIGHWAY 136
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:MO
Practice Address - Zip Code:64402-8223
Practice Address - Country:US
Practice Address - Phone:660-726-3333
Practice Address - Fax:660-726-3232
Is Sole Proprietor?:No
Enumeration Date:2015-10-06
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015035371363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2015035371OtherSTATE LICENSE