Provider Demographics
NPI:1942725965
Name:BIRD, TRAVIS H
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:H
Last Name:BIRD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5670 WYNN RD STE D
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89118-2355
Mailing Address - Country:US
Mailing Address - Phone:702-776-4114
Mailing Address - Fax:701-909-3757
Practice Address - Street 1:5670 WYNN RD STE D
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89118-2355
Practice Address - Country:US
Practice Address - Phone:702-776-4114
Practice Address - Fax:701-909-3757
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-10
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes331L00000XSuppliersBlood Bank
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH82-1780632OtherIRS