Provider Demographics
NPI:1013051317
Name:TRAVIS, AMBER MICHELLE (PA)
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:MICHELLE
Last Name:TRAVIS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:AMBER
Other - Middle Name:MICHELLE
Other - Last Name:ARAVE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 24410
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97402-0451
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3377 RIVERBEND DR
Practice Address - Street 2:PEDIATRIC SURGERY
Practice Address - City:SPRINGFIELD
Practice Address - State:OR
Practice Address - Zip Code:97477-8803
Practice Address - Country:US
Practice Address - Phone:541-222-6135
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-19
Last Update Date:2013-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA01206363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORQ76902Medicare UPIN