Provider Demographics
NPI:1780346072
Name:TRAVIS, LIISA MARIE (NP)
Entity type:Individual
Prefix:
First Name:LIISA
Middle Name:MARIE
Last Name:TRAVIS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17100B BEAR VALLEY RD # 283
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92395-5851
Mailing Address - Country:US
Mailing Address - Phone:209-499-4604
Mailing Address - Fax:
Practice Address - Street 1:12490 BUSINESS CENTER DR STE 100
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-5833
Practice Address - Country:US
Practice Address - Phone:760-552-8585
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-13
Last Update Date:2023-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95019345363L00000X
CA494033207T00000X, 163W00000X, 2086S0127X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
No163W00000XNursing Service ProvidersRegistered Nurse
No2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery