Basic Information
| Provider Information | |||||||||
| NPI: | 1376980367 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EWING | ||||||||
| FirstName: | TRAVIS | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1960 | ||||||||
| Address2: | |||||||||
| City: | JONESBORO | ||||||||
| State: | AR | ||||||||
| PostalCode: | 724031960 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8709368000 | ||||||||
| FaxNumber: | 8709343652 | ||||||||
| Practice Location | |||||||||
| Address1: | 1111 WINDOVER RD | ||||||||
| Address2: | |||||||||
| City: | JONESBORO | ||||||||
| State: | AR | ||||||||
| PostalCode: | 724016159 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8709368000 | ||||||||
| FaxNumber: | 8709343653 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2013 | ||||||||
| LastUpdateDate: | 08/10/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 08/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | E-8862 | AR | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207QS1201X | E8862 | AR | N | Allopathic & Osteopathic Physicians | Family Medicine | Sleep Medicine |
ID Information
| ID | Type | State | Issuer | Description | 221541003 | 05 | AR | MEDICAID |