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General NPI Number Information
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NPI Number | 1861990566
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Entity Type | Individual
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Provider Name | TRAVIS LANE THIBAULT
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Gender | Male
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Dates
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Enumeration Date | 01/28/2018
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Last Update Date | 07/27/2021
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Provider Practice Location Address
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Address Line | 8438 TIMBER RIDGE DR
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City | DE SOTO
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State | KS
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Zip | 66018-7122
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Country | US
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Telephone | 913-260-9250
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Fax |
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Provider Business Mailing Address
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Address Line | KANSAS EMERGENCY PHYSICIANS LLC 9100 W 74TH ST
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City | SHAWNEE MISSION
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State | KS
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Zip | 66204
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Country | US
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Telephone | 913-260-9250
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 2018001755
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License Number State | MO
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Taxonomy #2
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 78038
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License Number State | KS
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