Provider Demographics
NPI:1932743978
Name:ROSTAL, TRAVIS ALAN (PT, DPT)
Entity type:Individual
Prefix:
First Name:TRAVIS
Middle Name:ALAN
Last Name:ROSTAL
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:730 WASHINGTON ST APT 212
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:41011-3042
Mailing Address - Country:US
Mailing Address - Phone:801-389-4243
Mailing Address - Fax:
Practice Address - Street 1:3802 TURKEYFOOT RD
Practice Address - Street 2:
Practice Address - City:ELSMERE
Practice Address - State:KY
Practice Address - Zip Code:41018-2838
Practice Address - Country:US
Practice Address - Phone:859-342-0200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-02
Last Update Date:2019-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPT-007854225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY007854Medicaid