Provider Demographics
NPI:1801561170
Name:WATERSON, TRAVIS AARON
Entity type:Individual
Prefix:
First Name:TRAVIS
Middle Name:AARON
Last Name:WATERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3035 N KENTWOOD AVE APT A207
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65803-4573
Mailing Address - Country:US
Mailing Address - Phone:417-257-4588
Mailing Address - Fax:
Practice Address - Street 1:201 S NORTHPARK LN
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64801-8426
Practice Address - Country:US
Practice Address - Phone:417-623-4313
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-10
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2021027452225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant