Provider Demographics
NPI:1760266548
Name:TRAVIS, MARTINA
Entity Type:Individual
Prefix:
First Name:MARTINA
Middle Name:
Last Name:TRAVIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARTINA
Other - Middle Name:
Other - Last Name:TRAVIS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CRNA
Mailing Address - Street 1:200 MARY STREET, WILMINGTON, DE 19804
Mailing Address - Street 2:RICHARDSON PARK
Mailing Address - City:WILMINGTON, DE 19804
Mailing Address - State:DE
Mailing Address - Zip Code:19804
Mailing Address - Country:US
Mailing Address - Phone:302-588-7209
Mailing Address - Fax:
Practice Address - Street 1:4755 OGLETOWN STANTON RD
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19718-2200
Practice Address - Country:US
Practice Address - Phone:302-356-3085
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-22
Last Update Date:2023-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEL1-0045195367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered