Provider Demographics
NPI:1104043538
Name:TRAVERS, MARK M (DC)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:M
Last Name:TRAVERS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 KIRKLAND WAY
Mailing Address - Street 2:STE 105
Mailing Address - City:KIRKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98033-6021
Mailing Address - Country:US
Mailing Address - Phone:425-822-1859
Mailing Address - Fax:425-822-2920
Practice Address - Street 1:620 KIRKLAND WAY
Practice Address - Street 2:STE 105
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98033-6021
Practice Address - Country:US
Practice Address - Phone:425-822-1859
Practice Address - Fax:425-822-2920
Is Sole Proprietor?:No
Enumeration Date:2007-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH34314111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAU54593Medicare UPIN
WAG8857452Medicare ID - Type UnspecifiedINDIVIDUAL