Provider Demographics
NPI:1598934812
Name:WOLF, TRAVIS L (PA)
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:L
Last Name:WOLF
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 210
Mailing Address - Street 2:
Mailing Address - City:RIPON
Mailing Address - State:CA
Mailing Address - Zip Code:95366-0210
Mailing Address - Country:US
Mailing Address - Phone:209-599-4211
Mailing Address - Fax:209-599-4341
Practice Address - Street 1:150 VERA AVE
Practice Address - Street 2:
Practice Address - City:RIPON
Practice Address - State:CA
Practice Address - Zip Code:95366-2343
Practice Address - Country:US
Practice Address - Phone:209-599-4211
Practice Address - Fax:209-599-4341
Is Sole Proprietor?:No
Enumeration Date:2008-02-21
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA15708363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA15708OtherPHYSICIAN ASSIST