Healthcare Provider Details

I. General information

NPI: 1922259050
Provider Name (Legal Business Name): ERIC DEAN TRAVIS PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2008
Last Update Date: 11/03/2025
Certification Date: 11/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 LOIS LN
GREENWOOD WV
26415-9500
US

IV. Provider business mailing address

1 LOIS LN
GREENWOOD WV
26415-9500
US

V. Phone/Fax

Practice location:
  • Phone: 304-873-7020
  • Fax: 304-871-1857
Mailing address:
  • Phone: 702-386-4700
  • Fax: 304-873-1857

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2598
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: