Healthcare Provider Details

I. General information

NPI: 1740801299
Provider Name (Legal Business Name): TRAVIS CORY CALDARONE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/06/2020
Last Update Date: 03/05/2025
Certification Date: 03/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

235 N PEARL ST
BROCKTON MA
02301-1794
US

IV. Provider business mailing address

960 MASSACHUSETTS AVE STE 2
BOSTON MA
02118-2690
US

V. Phone/Fax

Practice location:
  • Phone: 508-427-3000
  • Fax:
Mailing address:
  • Phone: 617-414-5405
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number130335
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number092467-23
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: