Provider Demographics
NPI:1639810674
Name:PARKER, TRAVIS RYAN
Entity Type:Individual
Prefix:MR
First Name:TRAVIS
Middle Name:RYAN
Last Name:PARKER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5765 BOZEMAN DR APT 2401
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75024-5720
Mailing Address - Country:US
Mailing Address - Phone:469-734-1490
Mailing Address - Fax:
Practice Address - Street 1:5765 BOZEMAN DR APT 2401
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75024-5720
Practice Address - Country:US
Practice Address - Phone:469-734-1490
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-05
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX14364763172A00000X
TX872458653172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX872458653OtherTAX ID