Provider Demographics
NPI:1245853134
Name:LAWRENCE, TRAVIS JOHN
Entity type:Individual
Prefix:
First Name:TRAVIS
Middle Name:JOHN
Last Name:LAWRENCE
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 1:1268 MAPLE CT
Mailing Address - Street 2:
Mailing Address - City:HORNELL
Mailing Address - State:NY
Mailing Address - Zip Code:14843-9657
Mailing Address - Country:US
Mailing Address - Phone:607-382-5189
Mailing Address - Fax:
Practice Address - Street 1:1000 SOUTH AVE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14620-2733
Practice Address - Country:US
Practice Address - Phone:585-341-8130
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-26
Last Update Date:2023-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY431734363LA2200X
NYF431734-01363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health