Provider Demographics
NPI:1114289022
Name:WILSON, TRAVIS J (MD)
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:J
Last Name:WILSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16020 PARK VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:ROUND ROCK
Mailing Address - State:TX
Mailing Address - Zip Code:78681-3573
Mailing Address - Country:US
Mailing Address - Phone:512-244-0766
Mailing Address - Fax:512-244-1013
Practice Address - Street 1:16020 PARK VALLEY DR
Practice Address - Street 2:
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78681-3573
Practice Address - Country:US
Practice Address - Phone:512-244-0766
Practice Address - Fax:512-244-1013
Is Sole Proprietor?:No
Enumeration Date:2012-06-15
Last Update Date:2018-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXR8134207X00000X, 207XX0004X
WAMD60733507207XX0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0004XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryFoot and Ankle Surgery
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1114289022Medicaid