Healthcare Provider Details

I. General information

NPI: 1295383644
Provider Name (Legal Business Name): TRAVIS GUSTAFSON ELBERT PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2019
Last Update Date: 09/22/2026
Certification Date: 09/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1509 DOCTORS CIR BLDG C
WILMINGTON NC
28401-7403
US

IV. Provider business mailing address

700 E MOREHEAD ST STE 300
CHARLOTTE NC
28202-2742
US

V. Phone/Fax

Practice location:
  • Phone: 910-662-7500
  • Fax: 910-662-7501
Mailing address:
  • Phone: 704-334-7800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-09425
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: