Provider Demographics
NPI:1467962548
Name:AVERY, TRAVIS BENTLEY (PA-C)
Entity type:Individual
Prefix:
First Name:TRAVIS
Middle Name:BENTLEY
Last Name:AVERY
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9850 W ST LUKES DR
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83687-7912
Practice Address - Country:US
Practice Address - Phone:208-205-7600
Practice Address - Fax:208-205-7603
Is Sole Proprietor?:No
Enumeration Date:2017-10-03
Last Update Date:2025-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-1583363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant