Provider Demographics
NPI:1487628202
Name:TRAVIS, DANE SCOTT (MD)
Entity Type:Individual
Prefix:MR
First Name:DANE
Middle Name:SCOTT
Last Name:TRAVIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5343 TALLMAN AVE NW
Mailing Address - Street 2:SUITE 202
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98107
Mailing Address - Country:US
Mailing Address - Phone:206-547-0330
Mailing Address - Fax:206-789-0140
Practice Address - Street 1:5343 TALLMAN AVE NW
Practice Address - Street 2:SUITE 202
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98107
Practice Address - Country:US
Practice Address - Phone:206-547-0330
Practice Address - Fax:206-789-0140
Is Sole Proprietor?:No
Enumeration Date:2006-02-16
Last Update Date:2010-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00033916207Q00000X
HIMD9651207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1121086Medicaid
133038OtherL&I
133038OtherL&I
WA1121086Medicaid