Provider Demographics
NPI:1104465145
Name:NORTHERN, TRAVIS
Entity type:Individual
Prefix:
First Name:TRAVIS
Middle Name:
Last Name:NORTHERN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2997 OAK ST APT 205
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64108-3370
Mailing Address - Country:US
Mailing Address - Phone:417-342-7855
Mailing Address - Fax:
Practice Address - Street 1:800 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-5275
Practice Address - Country:US
Practice Address - Phone:573-814-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-21
Last Update Date:2019-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1304720208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation