Provider Demographics
NPI:1619947371
Name:TRAVIS, PAUL HERMAN (DC)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:HERMAN
Last Name:TRAVIS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3123 S 66TH ST
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72903-5005
Mailing Address - Country:US
Mailing Address - Phone:479-484-1400
Mailing Address - Fax:479-484-1400
Practice Address - Street 1:3123 S 66TH ST
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-5005
Practice Address - Country:US
Practice Address - Phone:479-484-1400
Practice Address - Fax:479-484-1400
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-25
Last Update Date:2013-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR942111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR105857-718Medicaid
AR105857-718Medicaid
AR59904Medicare ID - Type Unspecified