Healthcare Provider Details

I. General information

NPI: 1306807458
Provider Name (Legal Business Name): JAY H TRAVERSE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2006
Last Update Date: 03/11/2021
Certification Date: 03/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 E 28TH ST
MINNEAPOLIS MN
55407-3723
US

IV. Provider business mailing address

920 E 28TH ST STE 300
MINNEAPOLIS MN
55407-1195
US

V. Phone/Fax

Practice location:
  • Phone: 612-775-3030
  • Fax:
Mailing address:
  • Phone: 612-863-3900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number34287
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number34287
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: