Healthcare Provider Details

I. General information

NPI: 1417911025
Provider Name (Legal Business Name): TRAVIS M. HAYDEN PHYSICIAN ASSISTANT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2006
Last Update Date: 02/05/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 COULTER RD
CLIFTON SPRINGS NY
14432
US

IV. Provider business mailing address

100 WHITE SPRUCE BLVD
ROCHESTER NY
14623
US

V. Phone/Fax

Practice location:
  • Phone: 315-462-2267
  • Fax: 315-462-2003
Mailing address:
  • Phone: 585-272-0700
  • Fax: 585-272-8356

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number009141
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: