Provider Demographics
NPI:1528808128
Name:KEANE, TRAVIS ROBERT
Entity type:Individual
Prefix:
First Name:TRAVIS
Middle Name:ROBERT
Last Name:KEANE
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 1:3531 43RD ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92105-3401
Mailing Address - Country:US
Mailing Address - Phone:760-212-8408
Mailing Address - Fax:
Practice Address - Street 1:3531 43RD ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92105-3401
Practice Address - Country:US
Practice Address - Phone:760-212-8408
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-30
Last Update Date:2024-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95194403163WC0200X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine