Provider Demographics
NPI:1164186052
Name:ANDERSON, TRAVIS IAN (DC)
Entity Type:Individual
Prefix:MR
First Name:TRAVIS
Middle Name:IAN
Last Name:ANDERSON
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 1:3520 PAN AMERICAN FWY NE STE A1
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87107-4703
Mailing Address - Country:US
Mailing Address - Phone:505-308-8885
Mailing Address - Fax:
Practice Address - Street 1:3520 PAN AMERICAN FWY NE STE A1
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87107-4703
Practice Address - Country:US
Practice Address - Phone:505-308-8885
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-26
Last Update Date:2021-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDC2262111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty