Provider Demographics
NPI:1467791533
Name:TRAVIS, MARCUS GERARD (CST, CSA)
Entity Type:Individual
Prefix:MR
First Name:MARCUS
Middle Name:GERARD
Last Name:TRAVIS
Suffix:
Gender:M
Credentials:CST, CSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6811 ORVILLE ST
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77028-2139
Mailing Address - Country:US
Mailing Address - Phone:832-654-8459
Mailing Address - Fax:
Practice Address - Street 1:6811 ORVILLE ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77028-2139
Practice Address - Country:US
Practice Address - Phone:832-654-8459
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-08
Last Update Date:2013-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX363AS0400X363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical