Provider Demographics
NPI:1922304476
Name:ALLEN, TRAVIS (PA)
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:
Last Name:ALLEN
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 1:202 S 4TH ST W
Mailing Address - Street 2:
Mailing Address - City:BAKER
Mailing Address - State:MT
Mailing Address - Zip Code:59313-9156
Mailing Address - Country:US
Mailing Address - Phone:406-778-3331
Mailing Address - Fax:
Practice Address - Street 1:202 S 4TH ST W
Practice Address - Street 2:
Practice Address - City:BAKER
Practice Address - State:MT
Practice Address - Zip Code:59313-9156
Practice Address - Country:US
Practice Address - Phone:406-778-3331
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-02-01
Last Update Date:2016-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT645363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant