Provider Demographics
NPI:1265817688
Name:COOK, TRAVIS
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:
Last Name:COOK
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 1:580 E 600 N
Mailing Address - Street 2:
Mailing Address - City:PAYSON
Mailing Address - State:UT
Mailing Address - Zip Code:84651-1518
Mailing Address - Country:US
Mailing Address - Phone:801-310-3772
Mailing Address - Fax:
Practice Address - Street 1:9450 S 1300 E
Practice Address - Street 2:120
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84094-5555
Practice Address - Country:US
Practice Address - Phone:801-501-6150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-27
Last Update Date:2015-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant