Healthcare Provider Details

I. General information

NPI: 1992579262
Provider Name (Legal Business Name): TRAVIS ALAN COOK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2023
Last Update Date: 11/08/2023
Certification Date: 11/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1ST MAR RDR BN MRR MARFORSOC
CAMP LEJEUNE NC
28542
US

IV. Provider business mailing address

204 EGRET POINT DR
SNEADS FERRY NC
28460-9464
US

V. Phone/Fax

Practice location:
  • Phone: 910-440-3136
  • Fax:
Mailing address:
  • Phone: 956-279-0404
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number07222805TC
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: