Healthcare Provider Details

I. General information

NPI: 1992020432
Provider Name (Legal Business Name): TRAVIS G MARSHALL D.P.M
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2010
Last Update Date: 09/27/2023
Certification Date: 09/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

808 FREMONT ST
ASHTON ID
83420-1210
US

IV. Provider business mailing address

PO BOX 804
ASHTON ID
83420-0804
US

V. Phone/Fax

Practice location:
  • Phone: 307-359-9566
  • Fax:
Mailing address:
  • Phone: 307-359-9566
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberP-282
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number2008027655
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number141
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: