Provider Demographics
NPI:1609453380
Name:POULSON, TRAVIS JOHN (LAT, ATC, CSCS)
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:JOHN
Last Name:POULSON
Suffix:
Gender:M
Credentials:LAT, ATC, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N300 TOWER RD
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:WI
Mailing Address - Zip Code:53119-1914
Mailing Address - Country:US
Mailing Address - Phone:262-949-4026
Mailing Address - Fax:
Practice Address - Street 1:1910 UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83725-0002
Practice Address - Country:US
Practice Address - Phone:262-949-4026
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-27
Last Update Date:2021-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDAT-7132081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine