Provider Demographics
NPI:1295441103
Name:WILSON, TRAVIS (RDN)
Entity type:Individual
Prefix:
First Name:TRAVIS
Middle Name:
Last Name:WILSON
Suffix:
Gender:M
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2363 FERNWOOD CT
Mailing Address - Street 2:
Mailing Address - City:SPARKS
Mailing Address - State:NV
Mailing Address - Zip Code:89434-8039
Mailing Address - Country:US
Mailing Address - Phone:775-342-5712
Mailing Address - Fax:
Practice Address - Street 1:2363 FERNWOOD CT
Practice Address - Street 2:
Practice Address - City:SPARKS
Practice Address - State:NV
Practice Address - Zip Code:89434-8039
Practice Address - Country:US
Practice Address - Phone:775-342-5712
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-24
Last Update Date:2023-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered