Basic Information
| Provider Information | |||||||||
| NPI: | 1740375757 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CAMPBELL | ||||||||
| FirstName: | TRAVIS | ||||||||
| MiddleName: | REX | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 17765 W VENTURA ST | ||||||||
| Address2: | |||||||||
| City: | SURPRISE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853887603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6024895265 | ||||||||
| FaxNumber: | 6022120365 | ||||||||
| Practice Location | |||||||||
| Address1: | 10930 N TATUM BLVD | ||||||||
| Address2: | 103 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850286069 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6024895265 | ||||||||
| FaxNumber: | 6022120365 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2006 | ||||||||
| LastUpdateDate: | 04/24/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | 3505 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
No ID Information.