Basic Information
| Provider Information | |||||||||
| NPI: | 1811366925 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SPAETH | ||||||||
| FirstName: | TRACY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 325 MAINE STREET | ||||||||
| Address2: | MSO LIBRARY | ||||||||
| City: | LAWRENCE | ||||||||
| State: | KS | ||||||||
| PostalCode: | 66044 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7855052988 | ||||||||
| FaxNumber: | 7855055228 | ||||||||
| Practice Location | |||||||||
| Address1: | 330 ARKANSAS ST STE 215 | ||||||||
| Address2: | |||||||||
| City: | LAWRENCE | ||||||||
| State: | KS | ||||||||
| PostalCode: | 660441326 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7855052250 | ||||||||
| FaxNumber: | 7855055259 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/18/2015 | ||||||||
| LastUpdateDate: | 05/27/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/12/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 2015034069 | MO | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363L00000X | 53-76933 | KS | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.