Basic Information
| Provider Information | |||||||||
| NPI: | 1528039427 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TRACY | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | CATHERINE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | N.P. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SIWARSKI | ||||||||
| OtherFirstName: | ELIZABETH | ||||||||
| OtherMiddleName: | CATHERINE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | N.P. | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2130 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | MONTROSE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 814013834 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9702523123 | ||||||||
| FaxNumber: | 9702523208 | ||||||||
| Practice Location | |||||||||
| Address1: | 2130 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | MONTROSE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 814013834 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9702523123 | ||||||||
| FaxNumber: | 9702523208 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/30/2006 | ||||||||
| LastUpdateDate: | 01/20/2015 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | APN0991558NP | CO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363L00000X | RN0054045 | CO | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363L00000X | RXN0101115 | CO | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 04100095 | 05 | CO | MEDICAID | 22522859 | 05 | CO | MEDICAID |