Provider Demographics
NPI:1215914445
Name:SMITH, TRAVIS L (CRNA)
Entity type:Individual
Prefix:
First Name:TRAVIS
Middle Name:L
Last Name:SMITH
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:DEPT 86236
Mailing Address - Street 2:PO BOX 950195
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40295-0195
Mailing Address - Country:US
Mailing Address - Phone:502-473-2100
Mailing Address - Fax:502-456-6461
Practice Address - Street 1:1373 E STATE ROAD 62
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:IN
Practice Address - Zip Code:47250-7328
Practice Address - Country:US
Practice Address - Phone:812-801-0609
Practice Address - Fax:812-801-0276
Is Sole Proprietor?:No
Enumeration Date:2005-12-29
Last Update Date:2024-11-12
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
KY3004523367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200946180Medicaid
KY74009473Medicaid
KY74009473Medicaid