Provider Demographics
NPI:1699254136
Name:TRAVIS, JEREMY RYAN
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:RYAN
Last Name:TRAVIS
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 1:2845 WILL CLARKE PL
Mailing Address - Street 2:
Mailing Address - City:MORGANTON
Mailing Address - State:NC
Mailing Address - Zip Code:28655-8571
Mailing Address - Country:US
Mailing Address - Phone:828-448-8292
Mailing Address - Fax:
Practice Address - Street 1:1450 SHAIRE CENTER DR
Practice Address - Street 2:
Practice Address - City:LENOIR
Practice Address - State:NC
Practice Address - Zip Code:28645-7565
Practice Address - Country:US
Practice Address - Phone:828-728-6500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-07
Last Update Date:2018-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA6715225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant