Healthcare Provider Details

I. General information

NPI: 1235465931
Provider Name (Legal Business Name): TRAVIS M BROWN PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/30/2009
Last Update Date: 08/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 N JACKSON ST
JACKSON MI
49201-1266
US

IV. Provider business mailing address

3955 PATIENT CARE DR STE A
LANSING MI
48911-4271
US

V. Phone/Fax

Practice location:
  • Phone: 517-748-5500
  • Fax: 517-780-9286
Mailing address:
  • Phone: 517-908-0882
  • Fax: 517-908-0886

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601005570
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: