Provider Demographics
NPI:1962436253
Name:WILKINS, TRAVIS R (DC)
Entity type:Individual
Prefix:DR
First Name:TRAVIS
Middle Name:R
Last Name:WILKINS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:528 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:SHELLEY
Mailing Address - State:ID
Mailing Address - Zip Code:83274-1154
Mailing Address - Country:US
Mailing Address - Phone:208-357-0333
Mailing Address - Fax:208-357-2299
Practice Address - Street 1:528 N STATE ST
Practice Address - Street 2:
Practice Address - City:SHELLEY
Practice Address - State:ID
Practice Address - Zip Code:83274-1154
Practice Address - Country:US
Practice Address - Phone:208-357-0333
Practice Address - Fax:208-357-2299
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA-973111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDC4009OtherBLUE CROSS
ID1675438Medicare ID - Type UnspecifiedMEDICARE
IDU87672Medicare UPIN