Healthcare Provider Details

I. General information

NPI: 1982979175
Provider Name (Legal Business Name): TRAVIS MYKEL HAWKSLEY CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2012
Last Update Date: 10/22/2021
Certification Date: 10/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

93 CAMPUS AVE
LEWISTON ME
04240-6030
US

IV. Provider business mailing address

300 MAIN ST
LEWISTON ME
04240-7027
US

V. Phone/Fax

Practice location:
  • Phone: 207-777-8442
  • Fax: 207-777-8425
Mailing address:
  • Phone: 207-795-0111
  • Fax: 207-795-2766

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRNA153035
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: