MEDICARE: TRAVIS J SMITH PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	PA-954	ID
2	363A00000X	Physician Assistant
3	363A00000X	Physician Assistant	PA-7035	AZ

General Provider Information

NPI Number	:	1376810689
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TRAVIS J SMITH PA-C

Provider Business Mailing Address
First Line	:	3340 E GOLDSTONE WAY
Second Line	:
City	:	MERIDIAN
State	:	ID
Zip	:	83642-1026
Country	:	US
Telephone Number	:	208-302-7620
Fax Number	:	208-302-7615

Provider Business Practice Location Address
First Line	:	1 N CENTRAL AVE
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85004-4414
Country	:	US
Telephone Number	:	602-255-7520
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/01/2011
Last Update Date	:	04/22/2024

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