Provider Demographics
NPI:1689993958
Name:FUSSELMAN, TRAVIS JAMES (PA-C)
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:JAMES
Last Name:FUSSELMAN
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:P.O. BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-424-1400
Mailing Address - Fax:239-424-1421
Practice Address - Street 1:2776 CLEVELAND AVE
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33901-5864
Practice Address - Country:US
Practice Address - Phone:239-343-2606
Practice Address - Fax:239-343-3695
Is Sole Proprietor?:No
Enumeration Date:2010-05-25
Last Update Date:2013-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9105463363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP00924560OtherRAILROAD MEDICARE
FLP931492OtherOPTIMUM
FL9368561OtherAETNA
FL002247200Medicaid
FLP984378OtherFREEDOM HEALTH
FLP931492OtherOPTIMUM