Provider Demographics
NPI:1639251242
Name:LYTLE, TRAVIS (MSPT)
Entity type:Individual
Prefix:MR
First Name:TRAVIS
Middle Name:
Last Name:LYTLE
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 HUKU LII PL STE 101
Mailing Address - Street 2:
Mailing Address - City:KIHEI
Mailing Address - State:HI
Mailing Address - Zip Code:96753-7062
Mailing Address - Country:US
Mailing Address - Phone:808-879-0077
Mailing Address - Fax:808-879-0177
Practice Address - Street 1:411 HUKU LII PL STE 101
Practice Address - Street 2:
Practice Address - City:KIHEI
Practice Address - State:HI
Practice Address - Zip Code:96753-7062
Practice Address - Country:US
Practice Address - Phone:808-879-0077
Practice Address - Fax:808-879-0177
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2022-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT6994225100000X
HI55192251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT080006994CT24OtherANTHEM BC BS