Provider Demographics
NPI:1962667881
Name:FANN, WILLIAM TRAVIS (MS,ATC,PA-C)
Entity Type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:TRAVIS
Last Name:FANN
Suffix:
Gender:M
Credentials:MS,ATC,PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:13837 CIRCA CROSSING DR
Mailing Address - Street 2:
Mailing Address - City:LITHIA
Mailing Address - State:FL
Mailing Address - Zip Code:33547-4382
Mailing Address - Country:US
Mailing Address - Phone:813-684-2663
Mailing Address - Fax:813-658-6222
Practice Address - Street 1:13837 CIRCA CROSSING DR
Practice Address - Street 2:
Practice Address - City:LITHIA
Practice Address - State:FL
Practice Address - Zip Code:33547-4382
Practice Address - Country:US
Practice Address - Phone:813-684-2663
Practice Address - Fax:813-658-6222
Is Sole Proprietor?:No
Enumeration Date:2008-07-21
Last Update Date:2023-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
WAPA60703789363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1962667881Medicaid
WA1962667881Medicaid