Basic Information
| Provider Information | |||||||||
| NPI: | 1891239802 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRIES | ||||||||
| FirstName: | TRAVIS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1401 STEFFEN AVE | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452152338 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5135883623 | ||||||||
| FaxNumber: | 5135883649 | ||||||||
| Practice Location | |||||||||
| Address1: | 1401 STEFFEN AVE | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452152338 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5135883623 | ||||||||
| FaxNumber: | 5135883649 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/09/2016 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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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 | 363LF0000X | CNP 019867 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 0204999 | 05 | OH | MEDICAID |