Healthcare Provider Details

I. General information

NPI: 1992276240
Provider Name (Legal Business Name): TRAVIS LEE PRANGE PT, DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/16/2018
Last Update Date: 12/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5546 S FORT APACHE RD STE 100B
LAS VEGAS NV
89148-7693
US

IV. Provider business mailing address

4191 TARKIN AVE
LAS VEGAS NV
89120-4248
US

V. Phone/Fax

Practice location:
  • Phone: 702-798-4778
  • Fax: 702-798-4779
Mailing address:
  • Phone: 702-526-7894
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number3903
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: