Healthcare Provider Details

I. General information

NPI: 1003250440
Provider Name (Legal Business Name): TRAVIS WADE AUSTIN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2013
Last Update Date: 08/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4951 S WHITE MOUNTAIN RD BLDG A
SHOW LOW AZ
85901-7801
US

IV. Provider business mailing address

2200 E SHOW LOW LAKE RD
SHOW LOW AZ
85901-7831
US

V. Phone/Fax

Practice location:
  • Phone: 928-537-6700
  • Fax: 928-537-9581
Mailing address:
  • Phone: 928-537-6393
  • Fax: 928-532-2131

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207PH0002X
TaxonomyHospice and Palliative Medicine (Emergency Medicine) Physician
License Number58272
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code2083P0500X
TaxonomyPreventive Medicine/Occupational Environmental Medicine Physician
License Number58272
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: