Basic Information
| Provider Information | |||||||||
| NPI: | 1073760955 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TRACY | ||||||||
| FirstName: | TRACEY | ||||||||
| MiddleName: | KATHLEEN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HANRAHAN | ||||||||
| OtherFirstName: | TRACEY | ||||||||
| OtherMiddleName: | KATHLEEN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 506 4TH ST | ||||||||
| Address2: | |||||||||
| City: | LA GRANDE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 978501906 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5416633138 | ||||||||
| FaxNumber: | 5419755120 | ||||||||
| Practice Location | |||||||||
| Address1: | 506 4TH ST | ||||||||
| Address2: | |||||||||
| City: | LA GRANDE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97850 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5416633138 | ||||||||
| FaxNumber: | 5419755120 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/22/2008 | ||||||||
| LastUpdateDate: | 04/05/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD151037 | OR | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | MD60747878 | WA | N | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 500620109 | 05 | OR | MEDICAID | P00965892 | 01 | OR | RR MEDICARE | OTHER |