Provider Demographics
NPI:1407286016
Name:WAITES, TRAVIS
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:
Last Name:WAITES
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 1:10730 POTRANCO RD
Mailing Address - Street 2:STE 122-260
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78251-3327
Mailing Address - Country:US
Mailing Address - Phone:866-536-7629
Mailing Address - Fax:866-583-7570
Practice Address - Street 1:10730 POTRANCO RD
Practice Address - Street 2:STE 122-260
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78251-3327
Practice Address - Country:US
Practice Address - Phone:866-536-7629
Practice Address - Fax:866-583-7570
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-18
Last Update Date:2013-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies