Provider Demographics
NPI:1740801299
Name:CALDARONE, TRAVIS CORY
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:CORY
Last Name:CALDARONE
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 1:200 QUARRY HILLS DR APT 1528
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:MA
Mailing Address - Zip Code:02169-3856
Mailing Address - Country:US
Mailing Address - Phone:401-692-2393
Mailing Address - Fax:
Practice Address - Street 1:235 N PEARL ST
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-1794
Practice Address - Country:US
Practice Address - Phone:508-427-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-06
Last Update Date:2023-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA130335367500000X
NH092467-23363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered