Provider Demographics
NPI:1750710919
Name:GREEN, TRAVIS (PA-C)
Entity type:Individual
Prefix:
First Name:TRAVIS
Middle Name:
Last Name:GREEN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26671 ALISO CREEK RD
Mailing Address - Street 2:
Mailing Address - City:ALISO VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92656-4809
Mailing Address - Country:US
Mailing Address - Phone:949-791-3107
Mailing Address - Fax:
Practice Address - Street 1:26671 ALISO CREEK RD
Practice Address - Street 2:
Practice Address - City:ALISO VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92656-4809
Practice Address - Country:US
Practice Address - Phone:949-791-3107
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-07
Last Update Date:2025-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA60489241363A00000X
UT8818001-1206363AM0700X
CAPA54390363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8931677OtherMEDICARE PTAN
WA1750710919Medicaid