Basic Information
| Provider Information | |||||||||
| NPI: | 1871060681 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HENMAN | ||||||||
| FirstName: | TRAVIS | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 215 E HAWAII AVE | ||||||||
| Address2: | |||||||||
| City: | NAMPA | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836866011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2084633000 | ||||||||
| FaxNumber: | 2084633388 | ||||||||
| Practice Location | |||||||||
| Address1: | 1404 POMERELLE AVE STE 150 | ||||||||
| Address2: | |||||||||
| City: | BURLEY | ||||||||
| State: | ID | ||||||||
| PostalCode: | 833182012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2088788783 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/30/2018 | ||||||||
| LastUpdateDate: | 10/20/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.