Healthcare Provider Details

I. General information

NPI: 1275905416
Provider Name (Legal Business Name): TRAVIS MCDONALD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/27/2015
Last Update Date: 10/27/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 W UNIVERSITY AVE
MITCHELL SD
57301-4358
US

IV. Provider business mailing address

1905 MAPLE ST
TYNDALL SD
57066-2217
US

V. Phone/Fax

Practice location:
  • Phone: 605-661-2296
  • Fax:
Mailing address:
  • Phone: 605-661-2296
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateSD

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: