Healthcare Provider Details

I. General information

NPI: 1649706185
Provider Name (Legal Business Name): TRAVIS REID EDWARDS ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/03/2017
Last Update Date: 05/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1455 NE COLORADO ST
PULLMAN WA
99163
US

IV. Provider business mailing address

PO BOX 641602
PULLMAN WA
99164-1602
US

V. Phone/Fax

Practice location:
  • Phone: 509-335-0238
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberA160584184
License Number StateWA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier200014856
Identifier TypeOTHER
Identifier StateCA
Identifier IssuerBOARD OF CERTIFICATION
# 2
Identifier63370
Identifier TypeOTHER
Identifier StateCA
Identifier IssuerNATIONAL ATHLETIC TRAINERS' ASSOCIATION
# 3
IdentifierA160584184
Identifier TypeOTHER
Identifier StateWA
Identifier IssuerWASHINGTON STATE DEPARTMENT OF HEALTH, LICENSED ATHLETIC TRAINER

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: