Provider Demographics
NPI:1861990566
Name:THIBAULT, TRAVIS LANE
Entity type:Individual
Prefix:
First Name:TRAVIS
Middle Name:LANE
Last Name:THIBAULT
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:KANSAS EMERGENCY PHYSICIANS LLC
Mailing Address - Street 2:9100 W 74TH ST
Mailing Address - City:SHAWNEE MISSION
Mailing Address - State:KS
Mailing Address - Zip Code:66204
Mailing Address - Country:US
Mailing Address - Phone:913-260-9250
Mailing Address - Fax:
Practice Address - Street 1:8438 TIMBER RIDGE DR
Practice Address - Street 2:
Practice Address - City:DE SOTO
Practice Address - State:KS
Practice Address - Zip Code:66018-7122
Practice Address - Country:US
Practice Address - Phone:913-260-9250
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-28
Last Update Date:2021-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018001755363LF0000X
KS78038363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily