Provider Demographics
NPI:1659935872
Name:TAYLOR, TRAVIS JEROD
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:JEROD
Last Name:TAYLOR
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 1:17009 SUNNY HOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73012-6742
Mailing Address - Country:US
Mailing Address - Phone:405-306-4279
Mailing Address - Fax:
Practice Address - Street 1:23899 STATE HIGHWAY 74
Practice Address - Street 2:
Practice Address - City:PURCELL
Practice Address - State:OK
Practice Address - Zip Code:73080-6964
Practice Address - Country:US
Practice Address - Phone:405-253-3838
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-23
Last Update Date:2019-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist