Basic Information
| Provider Information | |||||||||
| NPI: | 1770984064 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TRACY | ||||||||
| FirstName: | KRISTIN | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3325 RESEARCH WAY | ||||||||
| Address2: | |||||||||
| City: | CARSON CITY | ||||||||
| State: | NV | ||||||||
| PostalCode: | 897067913 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7758886610 | ||||||||
| FaxNumber: | 7758884904 | ||||||||
| Practice Location | |||||||||
| Address1: | 1799 MOUNT MARIAH DR | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891061501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7023831961 | ||||||||
| FaxNumber: | 7023196147 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/06/2014 | ||||||||
| LastUpdateDate: | 07/15/2015 | ||||||||
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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 | 363A00000X | PA1552 | NV | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 1770984064 | 05 | NV | MEDICAID |