Basic Information
| Provider Information | |||||||||
| NPI: | 1972875334 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MATSUMOTO | ||||||||
| FirstName: | TRAVIS | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 920 COUNTRY CLUB RD STE 200A | ||||||||
| Address2: | |||||||||
| City: | EUGENE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974016086 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412424220 | ||||||||
| FaxNumber: | 5416866021 | ||||||||
| Practice Location | |||||||||
| Address1: | 920 COUNTRY CLUB RD STE 200A | ||||||||
| Address2: | |||||||||
| City: | EUGENE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974016086 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412424220 | ||||||||
| FaxNumber: | 5416866021 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2012 | ||||||||
| LastUpdateDate: | 10/31/2014 | ||||||||
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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 | 363AS0400X | PA156342 | OR | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363AM0700X | PA156342 | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | PA156342 | 01 | OR | STATE LICENSE | OTHER |