Healthcare Provider Details

I. General information

NPI: 1821770835
Provider Name (Legal Business Name): TRAVIS JOHN VACA CNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2023
Last Update Date: 08/01/2023
Certification Date: 08/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1325 S CLIFF AVE
SIOUX FALLS SD
57105-1007
US

IV. Provider business mailing address

27056 468TH AVE
TEA SD
57064-8003
US

V. Phone/Fax

Practice location:
  • Phone: 605-322-8000
  • Fax:
Mailing address:
  • Phone: 605-212-8161
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCP002912
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: