Basic Information
| Provider Information | |||||||||
| NPI: | 1164169561 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NELSON | ||||||||
| FirstName: | TRAVIS | ||||||||
| MiddleName: | HUNTER | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PT, DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4021 MCGINNIS FERRY RD APT 923 | ||||||||
| Address2: | |||||||||
| City: | SUWANEE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300248407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3342670393 | ||||||||
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| Practice Location | |||||||||
| Address1: | 104 BUILDERS PKWY | ||||||||
| Address2: | |||||||||
| City: | CORNELIA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 305315396 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6786163099 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2022 | ||||||||
| LastUpdateDate: | 05/17/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/17/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT015858 | GA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.