Healthcare Provider Details

I. General information

NPI: 1003853045
Provider Name (Legal Business Name): TRAVIS YATES DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/31/2006
Last Update Date: 07/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

REBEL DRIVE STUDENT HEALTH CENTER
UNIVERSITY MS
38677
US

IV. Provider business mailing address

701 QUIET VALLEY CV
OXFORD MS
38655-8430
US

V. Phone/Fax

Practice location:
  • Phone: 662-915-7274
  • Fax:
Mailing address:
  • Phone: 662-234-1881
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number9830
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: