Provider Demographics
NPI:1912443847
Name:WILLIAMS, TRAVIS JAMES
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:JAMES
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:732 HALLMARK DR
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-2832
Mailing Address - Country:US
Mailing Address - Phone:208-242-3376
Mailing Address - Fax:208-242-3245
Practice Address - Street 1:475 YELLOWSTONE AVE STE J
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-4528
Practice Address - Country:US
Practice Address - Phone:208-242-3376
Practice Address - Fax:208-242-3245
Is Sole Proprietor?:No
Enumeration Date:2017-01-17
Last Update Date:2022-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11012549363LF0000X
ID54931363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL11012549OtherFLORIDA APRN