Provider Demographics
NPI:1770513194
Name:WILBURN, TRAVIS RAY (FNP-C)
Entity type:Individual
Prefix:MR
First Name:TRAVIS
Middle Name:RAY
Last Name:WILBURN
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 1544
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:TX
Mailing Address - Zip Code:76430-1544
Mailing Address - Country:US
Mailing Address - Phone:325-762-3661
Mailing Address - Fax:325-762-3859
Practice Address - Street 1:450 KENSHALO
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:TX
Practice Address - Zip Code:76430
Practice Address - Country:US
Practice Address - Phone:325-762-3661
Practice Address - Fax:325-762-3859
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX671051363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX159515902Medicaid
TX0068NAOtherBCBS
TXP83222Medicare UPIN
TX00W222Medicare Oscar/Certification