Provider Demographics
NPI:1992020432
Name:MARSHALL, TRAVIS G (DPM)
Entity Type:Individual
Prefix:DR
First Name:TRAVIS
Middle Name:G
Last Name:MARSHALL
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 804
Mailing Address - Street 2:
Mailing Address - City:ASHTON
Mailing Address - State:ID
Mailing Address - Zip Code:83420-0804
Mailing Address - Country:US
Mailing Address - Phone:307-359-9566
Mailing Address - Fax:
Practice Address - Street 1:808 FREMONT ST
Practice Address - Street 2:
Practice Address - City:ASHTON
Practice Address - State:ID
Practice Address - Zip Code:83420-1210
Practice Address - Country:US
Practice Address - Phone:307-359-9566
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-27
Last Update Date:2023-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP-282213ES0103X
MO2008027655213E00000X
WY141213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist