Provider Demographics
NPI:1417431792
Name:BICKMORE, TRAVIS MICHAEL (PA-C)
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:MICHAEL
Last Name:BICKMORE
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 1:4052 MILLER ST
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15221-3942
Mailing Address - Country:US
Mailing Address - Phone:412-720-4804
Mailing Address - Fax:
Practice Address - Street 1:4815 LIBERTY AVE STE M02
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15224-2156
Practice Address - Country:US
Practice Address - Phone:412-578-1448
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-21
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOA004613363A00000X
PAMA060116363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
14339286OtherCAQH