Provider Demographics
NPI:1659484483
Name:HEADLEY, TRAVIS CHARLES (PA)
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:CHARLES
Last Name:HEADLEY
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 1:850 W IRONWOOD DR
Mailing Address - Street 2:SUITE 202
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-4903
Mailing Address - Country:US
Mailing Address - Phone:208-664-2175
Mailing Address - Fax:208-664-1226
Practice Address - Street 1:850 W IRONWOOD DR
Practice Address - Street 2:SUITE 202
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-4903
Practice Address - Country:US
Practice Address - Phone:208-664-2175
Practice Address - Fax:208-664-1226
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2023-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA406363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDPA406OtherLICENSE
IDPA406OtherLICENSE