Healthcare Provider Details

I. General information

NPI: 1518200575
Provider Name (Legal Business Name): TRAVIS JAMES PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/28/2013
Last Update Date: 02/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1325 W WHITTAKER ST SUITE 3
SALEM IL
62881-2007
US

IV. Provider business mailing address

1325 W WHITTAKER ST SUITE 3
SALEM IL
62881-2007
US

V. Phone/Fax

Practice location:
  • Phone: 618-548-2400
  • Fax: 618-548-2402
Mailing address:
  • Phone: 618-548-2400
  • Fax: 618-548-2402

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085.005204
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: