Provider Demographics
NPI:1912607417
Name:TRAVERS, WILTON B (RN)
Entity Type:Individual
Prefix:
First Name:WILTON
Middle Name:B
Last Name:TRAVERS
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6564 28TH ST S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104-4635
Mailing Address - Country:US
Mailing Address - Phone:701-730-7944
Mailing Address - Fax:
Practice Address - Street 1:6564 28TH ST S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104-4635
Practice Address - Country:US
Practice Address - Phone:701-730-7944
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-06
Last Update Date:2023-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDR504123747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant