Provider Demographics
NPI:1861822470
Name:FAY, TRAVAS (LPN)
Entity Type:Individual
Prefix:MR
First Name:TRAVAS
Middle Name:
Last Name:FAY
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4081 SWEET GUM LN
Mailing Address - Street 2:
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13090-1108
Mailing Address - Country:US
Mailing Address - Phone:315-857-1777
Mailing Address - Fax:
Practice Address - Street 1:4081 SWEET GUM LN
Practice Address - Street 2:
Practice Address - City:LIVERPOOL
Practice Address - State:NY
Practice Address - Zip Code:13090-1108
Practice Address - Country:US
Practice Address - Phone:315-857-1777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-18
Last Update Date:2013-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY313592-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse