Provider Demographics
NPI:1952607467
Name:WIES, TRAVIS J (NP)
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:J
Last Name:WIES
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 846098
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-6098
Mailing Address - Country:US
Mailing Address - Phone:903-324-6400
Mailing Address - Fax:
Practice Address - Street 1:1339 S BROADWAY ST
Practice Address - Street 2:
Practice Address - City:SULPHUR SPRINGS
Practice Address - State:TX
Practice Address - Zip Code:75482
Practice Address - Country:US
Practice Address - Phone:903-951-1001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-31
Last Update Date:2019-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP132187363LF0000X
NVAPRN001697363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX787723OtherMEDICARE
TXP02223412OtherMEDICARE RAIL ROAD
TX363776103Medicaid