Basic Information
| Provider Information | |||||||||
| NPI: | 1720188022 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | TRACEY | ||||||||
| MiddleName: | D. | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1241 W MINERAL AVE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | LITTLETON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801205685 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3037590854 | ||||||||
| FaxNumber: | 3037590864 | ||||||||
| Practice Location | |||||||||
| Address1: | 214 E 23RD ST | ||||||||
| Address2: | CHEYENNE REGIONAL MEDICAL CENTER, EMERGENCY DEPT. | ||||||||
| City: | CHEYENNE | ||||||||
| State: | WY | ||||||||
| PostalCode: | 820013748 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3076342273 | ||||||||
| FaxNumber: | 3076337671 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/25/2006 | ||||||||
| LastUpdateDate: | 05/11/2009 | ||||||||
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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 | 363LF0000X | 175880851 | WY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 123828100 | 05 | WY | MEDICAID | 35177837 | 05 | CO | MEDICAID | 314502 | 01 | WY | BCBS | OTHER |