Provider Demographics
NPI:1720733652
Name:WINGATE, TRAVIS DANIEL
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:DANIEL
Last Name:WINGATE
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 1:5460 AMANDA DR
Mailing Address - Street 2:
Mailing Address - City:LAURYS STATION
Mailing Address - State:PA
Mailing Address - Zip Code:18059-1334
Mailing Address - Country:US
Mailing Address - Phone:610-739-7781
Mailing Address - Fax:
Practice Address - Street 1:1551 PROFESSIONAL LN UNIT 145
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-6968
Practice Address - Country:US
Practice Address - Phone:720-494-3290
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-18
Last Update Date:2022-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPTL.0018214225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist