Healthcare Provider Details

I. General information

NPI: 1902751191
Provider Name (Legal Business Name): TRAVIS LYNN CLARY PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/03/2026
Last Update Date: 03/03/2026
Certification Date: 03/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

208 S BROOKWOOD DR APT 110
MOUNT HOREB WI
53572-3647
US

IV. Provider business mailing address

208 S BROOKWOOD DR APT 110
MOUNT HOREB WI
53572-3647
US

V. Phone/Fax

Practice location:
  • Phone: 920-904-7024
  • Fax:
Mailing address:
  • Phone: 920-904-7024
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: