Basic Information
Provider Information | |||||||||
NPI: | 1780346072 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | TRAVIS | ||||||||
FirstName: | LIISA | ||||||||
MiddleName: | MARIE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | NP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2409 FRANS HALS CIR | ||||||||
Address2: |   | ||||||||
City: | MODESTO | ||||||||
State: | CA | ||||||||
PostalCode: | 953560373 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2094994604 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 500 W HOSPITAL RD | ||||||||
Address2: |   | ||||||||
City: | FRENCH CAMP | ||||||||
State: | CA | ||||||||
PostalCode: | 952319693 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2094686000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/13/2021 | ||||||||
LastUpdateDate: | 07/25/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/25/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 494033 | CA | N |   | Nursing Service Providers | Registered Nurse |   | 207T00000X | 494033 | CA | N |   | Allopathic & Osteopathic Physicians | Neurological Surgery |   | 2086S0127X | 494033 | CA | N |   | Allopathic & Osteopathic Physicians | Surgery | Trauma Surgery | 363L00000X | 95019345 | CA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   |
No ID Information.