Provider Demographics
NPI:1831503259
Name:HARDIN, TRAVIS KEITH (PA-C)
Entity type:Individual
Prefix:
First Name:TRAVIS
Middle Name:KEITH
Last Name:HARDIN
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 1:101 RIVERSTONE VIS STE 111
Mailing Address - Street 2:
Mailing Address - City:BLUE RIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30513-6665
Mailing Address - Country:US
Mailing Address - Phone:706-946-4200
Mailing Address - Fax:706-492-3206
Practice Address - Street 1:101 RIVERSTONE VIS STE 111
Practice Address - Street 2:
Practice Address - City:BLUE RIDGE
Practice Address - State:GA
Practice Address - Zip Code:30513-6665
Practice Address - Country:US
Practice Address - Phone:706-946-4200
Practice Address - Fax:706-492-3206
Is Sole Proprietor?:No
Enumeration Date:2014-06-13
Last Update Date:2022-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPA2300363A00000X
GA7192363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1831503259Medicaid