Basic Information
| Provider Information | |||||||||
| NPI: | 1902491541 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | TRAVIS | ||||||||
| MiddleName: | Q | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LAC | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 4915 25TH AVE NE STE 104 | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981058667 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2063157998 | ||||||||
| FaxNumber: | 2063162308 | ||||||||
| Practice Location | |||||||||
| Address1: | 4915 25TH AVE NE STE 104 | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981058667 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2063157998 | ||||||||
| FaxNumber: | 2063162308 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/05/2021 | ||||||||
| LastUpdateDate: | 03/05/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 03/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171100000X | AC61091662 | WA | Y | Other Service Providers | Acupuncturist |
ID Information
| ID | Type | State | Issuer | Description | AC61091662 | 01 | WA | STATE | OTHER |