=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699388728
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TRAVIS PYKA APRN FNP-C CEN
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/28/2020
-----------------------------------------------------
Last Update Date | 08/16/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2979 MAIN ST
-----------------------------------------------------
City | BRIDGEPORT
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06606-4284
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 36-835-1002
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2979 MAIN ST
-----------------------------------------------------
City | BRIDGEPORT
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06606-4284
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 36-835-1002
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163WE0003X
-----------------------------------------------------
Taxonomy Name | Emergency Registered Nurse
-----------------------------------------------------
License Number | 161300
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 10298
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------