Healthcare Provider Details

I. General information

NPI: 1396446829
Provider Name (Legal Business Name): TRAVIS ROEDER PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/13/2023
Last Update Date: 03/13/2023
Certification Date: 03/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

318 RICHLAND WEST CIR
WACO TX
76712-7911
US

IV. Provider business mailing address

5106 LAKE PLACID PL
WACO TX
76710-2924
US

V. Phone/Fax

Practice location:
  • Phone: 254-776-8008
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: