Provider Demographics
NPI:1255982492
Name:PETRICK, TRAVIS (NP)
Entity type:Individual
Prefix:
First Name:TRAVIS
Middle Name:
Last Name:PETRICK
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15353 WEDDINGTON ST APT C107
Mailing Address - Street 2:
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91411-3844
Mailing Address - Country:US
Mailing Address - Phone:310-469-1374
Mailing Address - Fax:
Practice Address - Street 1:15353 WEDDINGTON ST APT C107
Practice Address - Street 2:
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91411-3844
Practice Address - Country:US
Practice Address - Phone:310-469-1374
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-27
Last Update Date:2019-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95012917363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care