Basic Information
| Provider Information | |||||||||
| NPI: | 1114289022 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | TRAVIS | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 16020 PARK VALLEY DR | ||||||||
| Address2: | |||||||||
| City: | ROUND ROCK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786813573 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5122440766 | ||||||||
| FaxNumber: | 5122441013 | ||||||||
| Practice Location | |||||||||
| Address1: | 16020 PARK VALLEY DR | ||||||||
| Address2: | |||||||||
| City: | ROUND ROCK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786813573 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5122440766 | ||||||||
| FaxNumber: | 5122441013 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2012 | ||||||||
| LastUpdateDate: | 08/27/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | R8134 | TX | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207XX0004X | MD60733507 | WA | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Foot and Ankle Surgery | 207XX0004X | R8134 | TX | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Foot and Ankle Surgery |
No ID Information.