Healthcare Provider Details

I. General information

NPI: 1952698243
Provider Name (Legal Business Name): DR. TRAVIS ALLEN OMURA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/07/2011
Last Update Date: 09/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

809A NW 53RD ST
SEATTLE WA
98107-3644
US

IV. Provider business mailing address

809A NW 53RD ST
SEATTLE WA
98107-3644
US

V. Phone/Fax

Practice location:
  • Phone: 970-314-3684
  • Fax:
Mailing address:
  • Phone: 970-314-3684
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMT200154
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMD60453867
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: