Provider Demographics
NPI:1417289869
Name:RYAN, TRAVIS WILSON (DC)
Entity Type:Individual
Prefix:DR
First Name:TRAVIS
Middle Name:WILSON
Last Name:RYAN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2147 HERNDON AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93611-6305
Mailing Address - Country:US
Mailing Address - Phone:559-297-0030
Mailing Address - Fax:559-297-7888
Practice Address - Street 1:2147 HERNDON AVE STE 104
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:CA
Practice Address - Zip Code:93611-6305
Practice Address - Country:US
Practice Address - Phone:559-297-0030
Practice Address - Fax:559-297-7888
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-10
Last Update Date:2017-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA31511111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor