Healthcare Provider Details

I. General information

NPI: 1376810689
Provider Name (Legal Business Name): TRAVIS J SMITH PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2011
Last Update Date: 04/22/2024
Certification Date: 04/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 N CENTRAL AVE
PHOENIX AZ
85004-4414
US

IV. Provider business mailing address

3340 E GOLDSTONE WAY
MERIDIAN ID
83642-1026
US

V. Phone/Fax

Practice location:
  • Phone: 602-255-7520
  • Fax:
Mailing address:
  • Phone: 208-302-7620
  • Fax: 208-302-7615

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA-954
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA-7035
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: