Provider Demographics
NPI:1639540131
Name:TAGGART, TRAVIS (PA-C)
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:
Last Name:TAGGART
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 1:808 RACHEL CT
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-4563
Mailing Address - Country:US
Mailing Address - Phone:909-800-4526
Mailing Address - Fax:
Practice Address - Street 1:808 RACHEL CT
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373-4563
Practice Address - Country:US
Practice Address - Phone:909-800-4526
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-09
Last Update Date:2015-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA52943363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant