Provider Demographics
NPI:1740375757
Name:CAMPBELL, TRAVIS REX (PA-C)
Entity type:Individual
Prefix:
First Name:TRAVIS
Middle Name:REX
Last Name:CAMPBELL
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:17765 W VENTURA ST
Mailing Address - Street 2:
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85388-7603
Mailing Address - Country:US
Mailing Address - Phone:602-489-5265
Mailing Address - Fax:602-212-0365
Practice Address - Street 1:10930 N TATUM BLVD
Practice Address - Street 2:103
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85028-6069
Practice Address - Country:US
Practice Address - Phone:602-489-5265
Practice Address - Fax:602-212-0365
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2012-04-24
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
AZ3505363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical