Healthcare Provider Details

I. General information

NPI: 1902180235
Provider Name (Legal Business Name): TRAVIS JOHN SHELTON O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/05/2011
Last Update Date: 10/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 S.MAIN ST.
LYMAN WY
82937-0429
US

IV. Provider business mailing address

PO BOX 429
LYMAN WY
82937-0429
US

V. Phone/Fax

Practice location:
  • Phone: 307-787-6123
  • Fax: 307-787-3351
Mailing address:
  • Phone: 307-787-6123
  • Fax: 307-787-3351

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number336T
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: