Provider Demographics
NPI:1992579262
Name:COOK, TRAVIS ALAN
Entity type:Individual
Prefix:
First Name:TRAVIS
Middle Name:ALAN
Last Name:COOK
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 1:204 EGRET POINT DR
Mailing Address - Street 2:
Mailing Address - City:SNEADS FERRY
Mailing Address - State:NC
Mailing Address - Zip Code:28460-9464
Mailing Address - Country:US
Mailing Address - Phone:956-279-0404
Mailing Address - Fax:
Practice Address - Street 1:1ST MAR RDR BN MRR MARFORSOC
Practice Address - Street 2:
Practice Address - City:CAMP LEJEUNE
Practice Address - State:NC
Practice Address - Zip Code:28542
Practice Address - Country:US
Practice Address - Phone:910-440-3136
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-08
Last Update Date:2023-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC07222805TC171000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171000000XOther Service ProvidersMilitary Health Care Provider