MEDICARE: ELLEN PEREZ TRAVIS NP

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	363LF0000X	Family Nurse Practitioner	418417-9309	CA

General Provider Information

NPI Number	:	1396743217
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELLEN PEREZ TRAVIS NP

Provider Business Mailing Address
First Line	:	542 VALLEY FORGE WAY
Second Line	:
City	:	CAMPBELL
State	:	CA
Zip	:	95008-0547
Country	:	US
Telephone Number	:	408-793-6771
Fax Number	:

Provider Business Practice Location Address
First Line	:	751 S BASCOM AVE
Second Line	:
City	:	SAN JOSE
State	:	CA
Zip	:	95128-2604
Country	:	US
Telephone Number	:	408-885-6780
Fax Number	:

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

Provider Enumeration Date	:	07/13/2005
Last Update Date	:	03/07/2023

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