Basic Information
| Provider Information | |||||||||
| NPI: | 1316178791 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TRAGER | ||||||||
| FirstName: | MATHAUS | ||||||||
| MiddleName: | Q | ||||||||
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| Credential: | CRNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1201 GRAMPIAN BLVD | ||||||||
| Address2: | SUITE 1K | ||||||||
| City: | WILLIAMSPORT | ||||||||
| State: | PA | ||||||||
| PostalCode: | 177011900 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 700 HIGH ST | ||||||||
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| City: | WILLIAMSPORT | ||||||||
| State: | PA | ||||||||
| PostalCode: | 177013198 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5703212800 | ||||||||
| FaxNumber: | 5703213351 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2009 | ||||||||
| LastUpdateDate: | 05/02/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | SP010378 | PA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363L00000X | 26NJ00543300 | NJ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 2641113 | 01 | PA | HIGHMARK BLUE SHIELD | OTHER | 0749359 | 01 | CIGNA | OTHER | 1026559160001 | 05 | PA | MEDICAID |