Provider Demographics
NPI:1780012997
Name:NICKELSON, TRAVIS RYAN (MSN, APRN)
Entity Type:Individual
Prefix:MR
First Name:TRAVIS
Middle Name:RYAN
Last Name:NICKELSON
Suffix:
Gender:M
Credentials:MSN, APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13809 W ALDERNY ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67235-7040
Mailing Address - Country:US
Mailing Address - Phone:620-727-7537
Mailing Address - Fax:
Practice Address - Street 1:5500 E KELLOGG DR
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67218-1607
Practice Address - Country:US
Practice Address - Phone:316-685-2221
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-24
Last Update Date:2013-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS53-76159363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care