Provider Demographics
NPI:1538651393
Name:STAFFORD, TRAVIS RYAN (DPT)
Entity type:Individual
Prefix:
First Name:TRAVIS
Middle Name:RYAN
Last Name:STAFFORD
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4443 W MOUNT COMFORT RD
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72704-5970
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2668 E CITIZENS DR STE 5
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-4796
Practice Address - Country:US
Practice Address - Phone:479-442-7473
Practice Address - Fax:479-239-5444
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-06
Last Update Date:2024-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPT5292225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200772810AMedicaid