Provider Demographics
NPI:1588376354
Name:OTA, TRAVIS-MITCHELL
Entity type:Individual
Prefix:
First Name:TRAVIS-MITCHELL
Middle Name:
Last Name:OTA
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 1:3138 WAIALAE AVE APT 113
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96816-1539
Mailing Address - Country:US
Mailing Address - Phone:808-225-9830
Mailing Address - Fax:
Practice Address - Street 1:3138 WAIALAE AVE APT 113
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96816-1539
Practice Address - Country:US
Practice Address - Phone:808-225-9830
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-23
Last Update Date:2022-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIPTA-669225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant