Basic Information
| Provider Information | |||||||||
| NPI: | 1679120661 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVISON | ||||||||
| FirstName: | TRAVIS | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 309 JORDAN DR | ||||||||
| Address2: | |||||||||
| City: | REDLANDS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923737137 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013583308 | ||||||||
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| Practice Location | |||||||||
| Address1: | 400 N PEPPER AVE | ||||||||
| Address2: | |||||||||
| City: | COLTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923241801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095801775 | ||||||||
| FaxNumber: | 9095802377 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2019 | ||||||||
| LastUpdateDate: | 09/18/2019 | ||||||||
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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 | 363A00000X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.