Healthcare Provider Details

I. General information

NPI: 1700169240
Provider Name (Legal Business Name): TRAVIS ROBERT NOVY APNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2011
Last Update Date: 05/27/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1506 S ONEIDA ST
APPLETON WI
54915-1305
US

IV. Provider business mailing address

1506 S ONEIDA ST AFFINITY MEDICAL GROUP
APPLETON WI
54915-1305
US

V. Phone/Fax

Practice location:
  • Phone: 920-730-6700
  • Fax: 920-730-6751
Mailing address:
  • Phone: 920-730-8700
  • Fax: 920-730-7691

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4581-033
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: