Provider Demographics
NPI:1699084814
Name:WEISS, TRAVIS JAMES (PA)
Entity type:Individual
Prefix:
First Name:TRAVIS
Middle Name:JAMES
Last Name:WEISS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6738 STATE HIGHWAY 77
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:MO
Mailing Address - Zip Code:63736-8238
Mailing Address - Country:US
Mailing Address - Phone:573-313-2500
Mailing Address - Fax:573-313-2505
Practice Address - Street 1:6724 STATE HIGHWAY 77
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:MO
Practice Address - Zip Code:63736-8238
Practice Address - Country:US
Practice Address - Phone:573-545-4200
Practice Address - Fax:573-545-4425
Is Sole Proprietor?:No
Enumeration Date:2010-10-05
Last Update Date:2020-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010034785363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical