Healthcare Provider Details

I. General information

NPI: 1790283331
Provider Name (Legal Business Name): WILLIAM TRAVIS HUPP PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/29/2018
Last Update Date: 01/11/2023
Certification Date: 01/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1124 GALLERY PARK LN
WILMINGTON NC
28412-1142
US

IV. Provider business mailing address

PO BOX 911244
DENVER CO
80291-1244
US

V. Phone/Fax

Practice location:
  • Phone: 910-395-3477
  • Fax: 910-815-3479
Mailing address:
  • Phone: 800-953-0104
  • Fax: 303-765-6640

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-10942
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA9110920
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA9110920
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: