Provider Demographics
NPI:1821711839
Name:RICHARDSON, TRAVIS (NP)
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:
Last Name:RICHARDSON
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3775 POLLINA AVE
Mailing Address - Street 2:
Mailing Address - City:FORT GRATIOT
Mailing Address - State:MI
Mailing Address - Zip Code:48059-4140
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3270 GREENFIELD RD
Practice Address - Street 2:
Practice Address - City:BERKLEY
Practice Address - State:MI
Practice Address - Zip Code:48072-1161
Practice Address - Country:US
Practice Address - Phone:248-268-1525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-23
Last Update Date:2022-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704307930363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily