Basic Information
| Provider Information | |||||||||
| NPI: | 1427474410 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DZUGAN | ||||||||
| FirstName: | TRACY | ||||||||
| MiddleName: | MICHELLE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | MS, RN, FNP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6360 TECHSTER BLVD | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339664805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2392232751 | ||||||||
| FaxNumber: | 2395612933 | ||||||||
| Practice Location | |||||||||
| Address1: | 2721 DEL PRADO BLVD S | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | CAPE CORAL | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339045781 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2392232751 | ||||||||
| FaxNumber: | 2395612933 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2014 | ||||||||
| LastUpdateDate: | 06/21/2016 | ||||||||
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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 | ARNP 9364680 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 011817700 | 05 | FL | MEDICAID |