Basic Information
| Provider Information | |||||||||
| NPI: | 1366453193 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SLADE | ||||||||
| FirstName: | TRAVIS | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2740 E 1700 N | ||||||||
| Address2: | |||||||||
| City: | LAYTON | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840407783 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8015466486 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5475 S 500 E | ||||||||
| Address2: | |||||||||
| City: | OGDEN | ||||||||
| State: | UT | ||||||||
| PostalCode: | 844056905 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8008803566 | ||||||||
| FaxNumber: | 8017335872 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 207L00000X | 5968724-1205 | UT | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 68295 | 01 | UT | PEHP | OTHER | 908627 | 01 | UT | DESERET MUTUAL | OTHER | 107040787101 | 01 | UT | IHC | OTHER | 346248 | 01 | UT | ALTIUS | OTHER | 6757 | 01 | UT | HEALTHY U | OTHER | QMP000003333370 | 01 | UT | MOLINA | OTHER |