Provider Demographics
NPI:1902894389
Name:LAYNE, TRAVIS KYLE (PAC)
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:KYLE
Last Name:LAYNE
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:380 ARNOLD RD
Mailing Address - Street 2:
Mailing Address - City:SHELBYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37160-7301
Mailing Address - Country:US
Mailing Address - Phone:615-347-1304
Mailing Address - Fax:
Practice Address - Street 1:1114 N MAIN ST STE B
Practice Address - Street 2:
Practice Address - City:SHELBYVILLE
Practice Address - State:TN
Practice Address - Zip Code:37160-2380
Practice Address - Country:US
Practice Address - Phone:615-347-1304
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-11
Last Update Date:2022-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPA580363AM0700X
UT10261499-1206363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
P09511Medicare UPIN
TN3669933Medicare ID - Type Unspecified
TN41177Z1OtherBCBS