Basic Information
Provider Information | |||||||||
NPI: | 1285698886 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WOLF | ||||||||
FirstName: | TRACY | ||||||||
MiddleName: | M | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | PLOCK | ||||||||
OtherFirstName: | TRACY | ||||||||
OtherMiddleName: | M | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | M.D. | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 500 W 144TH AVE STE 230 | ||||||||
Address2: |   | ||||||||
City: | WESTMINSTER | ||||||||
State: | CO | ||||||||
PostalCode: | 800239328 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3036652603 | ||||||||
FaxNumber: | 3036652605 | ||||||||
Practice Location | |||||||||
Address1: | 500 W 144TH AVE STE 230 | ||||||||
Address2: |   | ||||||||
City: | WESTMINSTER | ||||||||
State: | CO | ||||||||
PostalCode: | 800239328 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3036652603 | ||||||||
FaxNumber: | 3036652605 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/12/2006 | ||||||||
LastUpdateDate: | 10/16/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XS0106X | 34643 | CO | Y |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Hand Surgery |
ID Information
ID | Type | State | Issuer | Description | 1346436 | 05 | CO |   | MEDICAID | 400000680 | 01 | CO | RAILROAD MEDICARE | OTHER |