Healthcare Provider Details

I. General information

NPI: 1770513194
Provider Name (Legal Business Name): TRAVIS RAY WILBURN FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2006
Last Update Date: 12/09/2020
Certification Date: 12/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 KENSHALO
ALBANY TX
76430
US

IV. Provider business mailing address

P.O. BOX 1544
ALBANY TX
76430-1544
US

V. Phone/Fax

Practice location:
  • Phone: 325-762-3661
  • Fax: 325-762-3859
Mailing address:
  • Phone: 325-762-3661
  • Fax: 325-762-3859

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number671051
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: