Healthcare Provider Details

I. General information

NPI: 1053408591
Provider Name (Legal Business Name): TRAVIS B WILSON P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 W MAIN ST SUITE 100
SPRINGFIELD OH
45502-1312
US

IV. Provider business mailing address

140 W MAIN ST SUITE 100
SPRINGFIELD OH
45502-1312
US

V. Phone/Fax

Practice location:
  • Phone: 937-398-1066
  • Fax: 937-398-1076
Mailing address:
  • Phone: 937-398-1066
  • Fax: 937-398-1076

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1140
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2723
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: