Provider Demographics
NPI:1427344415
Name:HAMBLIN, TRAVIS (DO)
Entity type:Individual
Prefix:
First Name:TRAVIS
Middle Name:
Last Name:HAMBLIN
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:PO BOX 1792
Mailing Address - Street 2:
Mailing Address - City:HIGLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85236-1792
Mailing Address - Country:US
Mailing Address - Phone:928-532-7546
Mailing Address - Fax:923-532-7547
Practice Address - Street 1:5300 S SUTTER DR STE 1
Practice Address - Street 2:
Practice Address - City:SHOW LOW
Practice Address - State:AZ
Practice Address - Zip Code:85901-8055
Practice Address - Country:US
Practice Address - Phone:928-532-7546
Practice Address - Fax:923-532-7547
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-28
Last Update Date:2024-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ006585207N00000X
MI5101019474390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ006156Medicaid
AZZ176975OtherPTAN