Healthcare Provider Details

I. General information

NPI: 1811990658
Provider Name (Legal Business Name): TRAVIS D. JORDAN D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2005
Last Update Date: 08/24/2022
Certification Date: 08/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 HUEBNER RD
FORT RILEY KS
66442-4030
US

IV. Provider business mailing address

448 W 7TH ST
CONCORDIA KS
66901-2706
US

V. Phone/Fax

Practice location:
  • Phone: 785-239-7777
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0530032
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: