Provider Demographics
NPI:1831517333
Name:PHILLIPPI, TRAVIS LANE (PA-C)
Entity type:Individual
Prefix:MR
First Name:TRAVIS
Middle Name:LANE
Last Name:PHILLIPPI
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5959 S SHERWOOD FOREST BLVD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816-6038
Mailing Address - Country:US
Mailing Address - Phone:225-526-0011
Mailing Address - Fax:225-765-9196
Practice Address - Street 1:7777 HENNESSY BLVD STE 8001
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70808
Practice Address - Country:US
Practice Address - Phone:225-490-7224
Practice Address - Fax:225-490-7223
Is Sole Proprietor?:No
Enumeration Date:2014-04-01
Last Update Date:2021-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2505363A00000X
LA320838363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ010359Medicaid
TN6028588OtherBCBST
TNQ010359Medicaid