Provider Demographics
NPI:1689760845
Name:SHOCK, TRAVIS JON (ATC)
Entity Type:Individual
Prefix:MR
First Name:TRAVIS
Middle Name:JON
Last Name:SHOCK
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1510 AVENUE B
Mailing Address - Street 2:
Mailing Address - City:WAHPETON
Mailing Address - State:ND
Mailing Address - Zip Code:58075-3760
Mailing Address - Country:US
Mailing Address - Phone:701-672-4513
Mailing Address - Fax:
Practice Address - Street 1:2400 32ND AVE S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-5800
Practice Address - Country:US
Practice Address - Phone:218-643-2694
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN17922255A2300X
ND271-032255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer