Provider Demographics
NPI:1689923732
Name:WHITESIDES, TRAVIS GLENN (PA-C)
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:GLENN
Last Name:WHITESIDES
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 1:309 SANDERS ST
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:KS
Mailing Address - Zip Code:66839-2616
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:309 SANDERS ST
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:KS
Practice Address - Zip Code:66839-2616
Practice Address - Country:US
Practice Address - Phone:620-364-2121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-05
Last Update Date:2019-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019017032363A00000X
KS15-01559363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant