Healthcare Provider Details

I. General information

NPI: 1447733522
Provider Name (Legal Business Name): SAMUEL D TRAVIS CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2018
Last Update Date: 03/02/2023
Certification Date: 03/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 W 9TH ST
HOISINGTON KS
67544-1706
US

IV. Provider business mailing address

8080 E CENTRAL AVE STE 250
WICHITA KS
67206-2367
US

V. Phone/Fax

Practice location:
  • Phone: 620-653-2114
  • Fax: 620-653-2350
Mailing address:
  • Phone: 316-686-7327
  • Fax: 316-686-1557

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number557629
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: