Provider Demographics
NPI:1053408591
Name:WILSON, TRAVIS B (PA)
Entity type:Individual
Prefix:
First Name:TRAVIS
Middle Name:B
Last Name:WILSON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 W MAIN ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45502-1312
Mailing Address - Country:US
Mailing Address - Phone:937-398-1066
Mailing Address - Fax:937-398-1076
Practice Address - Street 1:140 W MAIN ST
Practice Address - Street 2:SUITE 100
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45502-1312
Practice Address - Country:US
Practice Address - Phone:937-398-1066
Practice Address - Fax:937-398-1076
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1140363A00000X
OH2723363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2723OtherPA LICENSE
OH11949409OtherCAQH
OHMW2183060OtherDEA
OH11949409OtherCAQH
OHAA16145684Medicare PIN
OH2723OtherPA LICENSE
OHMW2183060OtherDEA
OHWIPA30481Medicare PIN