Provider Demographics
NPI:1225401219
Name:GROSS, TRAVIS RYAN
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:RYAN
Last Name:GROSS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 LOWER PLN
Mailing Address - Street 2:
Mailing Address - City:BRADFORD
Mailing Address - State:VT
Mailing Address - Zip Code:05033-8924
Mailing Address - Country:US
Mailing Address - Phone:802-222-9292
Mailing Address - Fax:
Practice Address - Street 1:901 LOWER PLN
Practice Address - Street 2:
Practice Address - City:BRADFORD
Practice Address - State:VT
Practice Address - Zip Code:05033
Practice Address - Country:US
Practice Address - Phone:802-222-9292
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-12
Last Update Date:2019-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY061088183500000X
VT033.0134102183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist