Healthcare Provider Details

I. General information

NPI: 1760749337
Provider Name (Legal Business Name): TRAVIS DEYTON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/19/2012
Last Update Date: 04/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1924 ALCOA HWY SUITE E 210
KNOXVILLE TN
37920-1511
US

IV. Provider business mailing address

7320 EDNA DR
KNOXVILLE TN
37920-6689
US

V. Phone/Fax

Practice location:
  • Phone: 865-524-7471
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number16656
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: