Basic Information
| Provider Information | |||||||||
| NPI: | 1083842520 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROSS | ||||||||
| FirstName: | TRACY | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | APN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1387 W 4TH ST | ||||||||
| Address2: | |||||||||
| City: | TAHLEQUAH | ||||||||
| State: | OK | ||||||||
| PostalCode: | 744649766 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9184535554 | ||||||||
| FaxNumber: | 9184314112 | ||||||||
| Practice Location | |||||||||
| Address1: | 1387 W 4TH ST | ||||||||
| Address2: | |||||||||
| City: | TAHLEQUAH | ||||||||
| State: | OK | ||||||||
| PostalCode: | 744649766 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9184535554 | ||||||||
| FaxNumber: | 9184314112 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2009 | ||||||||
| LastUpdateDate: | 07/23/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | A01450ANP | AR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LG0600X | 09035013 | OK | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology |
No ID Information.