Provider Demographics
NPI:1053691238
Name:SWIFT, TRAVIS JAY (PA-C)
Entity type:Individual
Prefix:
First Name:TRAVIS
Middle Name:JAY
Last Name:SWIFT
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 1:1490 E FOREMASTER DR STE 200
Mailing Address - Street 2:
Mailing Address - City:SAINT GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84790-4496
Mailing Address - Country:US
Mailing Address - Phone:435-628-1641
Mailing Address - Fax:
Practice Address - Street 1:1490 E FOREMASTER DR STE 200
Practice Address - Street 2:
Practice Address - City:SAINT GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790-4496
Practice Address - Country:US
Practice Address - Phone:435-628-1641
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-19
Last Update Date:2018-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-03061363AS0400X
UT5419926-1206363AS0400X
AZ5153363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ102176Medicare PIN