Provider Demographics
NPI:1376144048
Name:PHILLIPS, TRAVIS THOMAS
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:THOMAS
Last Name:PHILLIPS
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 1:2912 HARGETTE RD
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:NC
Mailing Address - Zip Code:28112-8142
Mailing Address - Country:US
Mailing Address - Phone:336-653-6599
Mailing Address - Fax:
Practice Address - Street 1:2912 HARGETTE RD
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:NC
Practice Address - Zip Code:28112-8142
Practice Address - Country:US
Practice Address - Phone:336-653-6599
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-08
Last Update Date:2020-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program