Provider Demographics
NPI:1821393539
Name:NORTH, TRAVIS JAMES (PA)
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:JAMES
Last Name:NORTH
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1055 N 500 W
Mailing Address - Street 2:ATTN CREDENTIALING
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-3305
Mailing Address - Country:US
Mailing Address - Phone:801-354-8225
Mailing Address - Fax:801-418-0941
Practice Address - Street 1:1055 N 500 W BLDG A
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-3305
Practice Address - Country:US
Practice Address - Phone:801-812-5033
Practice Address - Fax:801-812-5034
Is Sole Proprietor?:No
Enumeration Date:2011-01-11
Last Update Date:2022-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
UT390200000X
UT8261139-1206363A00000X
UT1821393539390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1821393539Medicaid