Provider Demographics
NPI:1396440848
Name:WHEELER, TRAVIS ROBERT (DO)
Entity type:Individual
Prefix:DR
First Name:TRAVIS
Middle Name:ROBERT
Last Name:WHEELER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:391 MYRTLE AVE
Mailing Address - Street 2:DEPARTMENT OF VASCULAR SURGERY, MAILING CODE 157
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12208-3835
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:391 MYRTLE AVE
Practice Address - Street 2:DEPARTMENT OF VASCULAR SURGERY, MAILING CODE 157
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12208-3835
Practice Address - Country:US
Practice Address - Phone:518-262-6946
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-04
Last Update Date:2023-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY390200000X390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY64850Medicaid