Provider Demographics
NPI:1952157430
Name:FORTNEY, TRAVIS WILLIAM (PA-C)
Entity type:Individual
Prefix:
First Name:TRAVIS
Middle Name:WILLIAM
Last Name:FORTNEY
Suffix:
Gender:
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 1:1642 MAPLE DR
Mailing Address - Street 2:
Mailing Address - City:LORAIN
Mailing Address - State:OH
Mailing Address - Zip Code:44052-2846
Mailing Address - Country:US
Mailing Address - Phone:440-258-9217
Mailing Address - Fax:
Practice Address - Street 1:1400 W PLEASANT VALLEY RD
Practice Address - Street 2:
Practice Address - City:PARMA
Practice Address - State:OH
Practice Address - Zip Code:44134-6720
Practice Address - Country:US
Practice Address - Phone:440-882-6595
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-25
Last Update Date:2025-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.009153RX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant