Provider Demographics
NPI:1770393415
Name:SAMPLES, TRAVIS (PA-C)
Entity type:Individual
Prefix:
First Name:TRAVIS
Middle Name:
Last Name:SAMPLES
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 1:1796 BAYVIEW DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46815-4219
Mailing Address - Country:US
Mailing Address - Phone:734-807-1260
Mailing Address - Fax:
Practice Address - Street 1:608 UNION CHAPEL RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-9357
Practice Address - Country:US
Practice Address - Phone:260-482-5091
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-13
Last Update Date:2025-01-13
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical