Healthcare Provider Details

I. General information

NPI: 1831795327
Provider Name (Legal Business Name): TRAVIS JOHN LAVERNE PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/09/2020
Last Update Date: 06/06/2024
Certification Date: 05/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 NJ-73
VOORHEES TOWNSHIP NJ
08043
US

IV. Provider business mailing address

100 NJ-73
VOORHEES TOWNSHIP NJ
08043
US

V. Phone/Fax

Practice location:
  • Phone: 856-282-1338
  • Fax:
Mailing address:
  • Phone: 856-282-1338
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number25MP00616900
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number25MP00616900
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: