Provider Demographics
NPI:1114329497
Name:WALLING, TRAVIS (APRN)
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:
Last Name:WALLING
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 S WALDRON RD
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72903-2550
Mailing Address - Country:US
Mailing Address - Phone:479-221-9988
Mailing Address - Fax:
Practice Address - Street 1:7800 DALLAS ST
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-4278
Practice Address - Country:US
Practice Address - Phone:479-259-9394
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-18
Last Update Date:2023-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA004204363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health