Provider Demographics
NPI:1710281894
Name:BUCHANAN, TRAVIS JAMES (PA-C)
Entity type:Individual
Prefix:MR
First Name:TRAVIS
Middle Name:JAMES
Last Name:BUCHANAN
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:PO BOX 74008272
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60674-8272
Mailing Address - Country:US
Mailing Address - Phone:702-899-0595
Mailing Address - Fax:702-977-1496
Practice Address - Street 1:4304 W HOUSTON ST
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-4519
Practice Address - Country:US
Practice Address - Phone:872-231-3162
Practice Address - Fax:702-977-1496
Is Sole Proprietor?:No
Enumeration Date:2011-01-04
Last Update Date:2025-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1939363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1939OtherOKLAHOMA STATE BOARD OF MEDICAL LICENSURE AND SUPERVISION
OK200319100AMedicaid