Provider Demographics
NPI:1932627924
Name:LEE, TRAVIS JACK (PTA)
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:JACK
Last Name:LEE
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5020 SE 30TH AVE APT 97
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202-4551
Mailing Address - Country:US
Mailing Address - Phone:360-540-7700
Mailing Address - Fax:
Practice Address - Street 1:1939 SW TROON AVE
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97702-3143
Practice Address - Country:US
Practice Address - Phone:503-468-8592
Practice Address - Fax:888-394-2351
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-30
Last Update Date:2017-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR09474225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant