Healthcare Provider Details

I. General information

NPI: 1912451618
Provider Name (Legal Business Name): JANE TRAVIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2016
Last Update Date: 02/12/2020
Certification Date: 02/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8118 GOOD LUCK RD
LANHAM MD
20706-3574
US

IV. Provider business mailing address

127 3RD ST NE
WASHINGTON DC
20002-7313
US

V. Phone/Fax

Practice location:
  • Phone: 301-552-8665
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA031277
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: