Healthcare Provider Details

I. General information

NPI: 1750897534
Provider Name (Legal Business Name): TRAVIS JAMES HARGREAVES
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/16/2017
Last Update Date: 08/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3701 12TH ST N STE 202
SAINT CLOUD MN
56303
US

IV. Provider business mailing address

18034 QUEEN ST NW
ELK RIVER MN
55330-1662
US

V. Phone/Fax

Practice location:
  • Phone: 320-251-2700
  • Fax:
Mailing address:
  • Phone: 308-765-1072
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number120518
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number71435
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: