Healthcare Provider Details

I. General information

NPI: 1801205984
Provider Name (Legal Business Name): TRAVIS WAYNE URBATCH PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2014
Last Update Date: 08/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3366 OAKDALE AVE N SUITE 103
ROBBINSDALE MN
55422-2948
US

IV. Provider business mailing address

4200 DAHLBERG DR SUITE 300
GOLDEN VALLEY MN
55422-4840
US

V. Phone/Fax

Practice location:
  • Phone: 763-520-7870
  • Fax: 763-520-7580
Mailing address:
  • Phone: 952-512-5600
  • Fax: 952-512-5651

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2137
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: