Provider Demographics
NPI:1225608078
Name:TRAVIS, JOSHUA BLAKE (DNP)
Entity Type:Individual
Prefix:
First Name:JOSHUA
Middle Name:BLAKE
Last Name:TRAVIS
Suffix:
Gender:M
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 MARION AVE
Mailing Address - Street 2:
Mailing Address - City:MCCOMB
Mailing Address - State:MS
Mailing Address - Zip Code:39648-2705
Mailing Address - Country:US
Mailing Address - Phone:601-249-5500
Mailing Address - Fax:
Practice Address - Street 1:215 MARION AVE
Practice Address - Street 2:
Practice Address - City:MCCOMB
Practice Address - State:MS
Practice Address - Zip Code:39648-2705
Practice Address - Country:US
Practice Address - Phone:601-249-5500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-24
Last Update Date:2023-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS904178163WC0200X
MS901853367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine