Healthcare Provider Details

I. General information

NPI: 1538631866
Provider Name (Legal Business Name): TRAVIS GRAY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/27/2018
Last Update Date: 01/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

602 INDIANA AVE
LUBBOCK TX
79415-3364
US

IV. Provider business mailing address

5420 71ST ST
LUBBOCK TX
79424-2000
US

V. Phone/Fax

Practice location:
  • Phone: 806-775-8200
  • Fax:
Mailing address:
  • Phone: 806-231-9989
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAP140162
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: