Provider Demographics
NPI:1578712196
Name:TRAVIS, MICHAEL (PA-C)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:
Last Name:TRAVIS
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 1:6104 AVENUE Q SOUTH DR
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79412-3700
Mailing Address - Country:US
Mailing Address - Phone:806-472-3430
Mailing Address - Fax:806-472-3432
Practice Address - Street 1:6104 AVENUE Q SOUTH DR
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79412-3700
Practice Address - Country:US
Practice Address - Phone:806-472-3430
Practice Address - Fax:806-472-3432
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-18
Last Update Date:2008-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA01707363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical