Basic Information
| Provider Information | |||||||||
| NPI: | 1134515984 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TRACEY | ||||||||
| FirstName: | MARY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8745 COUNTY ROAD 9 S | ||||||||
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| City: | ALAMOSA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 811019610 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 52 VILLAGE DR | ||||||||
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| City: | PAGOSA SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 811478368 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9702642104 | ||||||||
| FaxNumber: | 9702642108 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/08/2015 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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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 | 363LP0808X | APN.0993060-NP | CO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.