Basic Information
| Provider Information | |||||||||
| NPI: | 1932159183 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PANTZKE | ||||||||
| FirstName: | TRACI | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CRNA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | OLSON | ||||||||
| OtherFirstName: | TRACI | ||||||||
| OtherMiddleName: | LYNN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | CRNA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2301 25TH ST S | ||||||||
| Address2: | STE K | ||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581036104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7012341728 | ||||||||
| FaxNumber: | 7012341628 | ||||||||
| Practice Location | |||||||||
| Address1: | 2301 25TH ST S | ||||||||
| Address2: | STE K | ||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581036104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7012341728 | ||||||||
| FaxNumber: | 7012341628 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2006 | ||||||||
| LastUpdateDate: | 11/15/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | R22825 | ND | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 020823 | 01 | ND | ND BLUE SHIELD | OTHER | 131R8PA | 01 | MN | MN BLUE SHIELD | OTHER | 10221 | 05 | ND | MEDICAID |