Provider Demographics
NPI:1962585752
Name:WEISZHAAR, TRAVIS J (PA-C)
Entity type:Individual
Prefix:
First Name:TRAVIS
Middle Name:J
Last Name:WEISZHAAR
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37 S 2ND E
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-1906
Mailing Address - Country:US
Mailing Address - Phone:208-356-0234
Mailing Address - Fax:208-356-9141
Practice Address - Street 1:37 S 2ND E
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-1906
Practice Address - Country:US
Practice Address - Phone:208-356-0234
Practice Address - Fax:208-356-9141
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA264363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID8041599100Medicaid
ID1377619Medicare ID - Type Unspecified
ID8041599100Medicaid