Provider Demographics
NPI:1316457534
Name:ROBERTS, TRAVIS WAYNE (NP-C)
Entity type:Individual
Prefix:
First Name:TRAVIS
Middle Name:WAYNE
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:975 SOLOMONS ISLAND RD N
Mailing Address - Street 2:
Mailing Address - City:PRINCE FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:20678-3917
Mailing Address - Country:US
Mailing Address - Phone:240-682-6249
Mailing Address - Fax:
Practice Address - Street 1:975 SOLOMONS ISLAND RD N
Practice Address - Street 2:
Practice Address - City:PRINCE FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:20678-3917
Practice Address - Country:US
Practice Address - Phone:410-535-5400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-02
Last Update Date:2022-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR205253363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
1861849051OtherNPI
1902955396OtherNPI