Basic Information
| Provider Information | |||||||||
| NPI: | 1639185739 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TRAEGER | ||||||||
| FirstName: | MARC | ||||||||
| MiddleName: | STEVEN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 860 | ||||||||
| Address2: | |||||||||
| City: | WHITERIVER | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 859410860 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9283384911 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 801 ENCINO PL NE STE 14 | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 87102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052721777 | ||||||||
| FaxNumber: | 5052722360 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2006 | ||||||||
| LastUpdateDate: | 08/24/2018 | ||||||||
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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 | 207Q00000X | 17404 | AZ | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | MD2018-0258 | NM | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1629236716 | 05 | AZ | MEDICAID | 1295993376 | 05 | AZ | MEDICAID | 1780614008 | 05 | AZ | MEDICAID | 1871523191 | 05 | AZ | MEDICAID | 409715 | 05 | AZ | MEDICAID |