Provider Demographics
NPI:1245609106
Name:BUCHANAN, TRAVIS J (PA-C)
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:J
Last Name:BUCHANAN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 E LIBERTY ST
Mailing Address - Street 2:SUITE 800
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-1434
Mailing Address - Country:US
Mailing Address - Phone:502-749-7909
Mailing Address - Fax:502-749-9397
Practice Address - Street 1:5295 PRESERVE PKWY STE 260
Practice Address - Street 2:
Practice Address - City:HOOVER
Practice Address - State:AL
Practice Address - Zip Code:35244-4703
Practice Address - Country:US
Practice Address - Phone:205-380-9761
Practice Address - Fax:205-380-1957
Is Sole Proprietor?:No
Enumeration Date:2015-09-22
Last Update Date:2019-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA2102363A00000X
AL1080363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100422800Medicaid
KY7100422800Medicaid