Basic Information
| Provider Information | |||||||||
| NPI: | 1942453113 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DICKERSON | ||||||||
| FirstName: | TRACY | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 SEAGATE # 800 | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436041558 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4196907900 | ||||||||
| FaxNumber: | 4196977726 | ||||||||
| Practice Location | |||||||||
| Address1: | 2801 BAY PARK DR | ||||||||
| Address2: | |||||||||
| City: | OREGON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436164920 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4196907900 | ||||||||
| FaxNumber: | 4196977726 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2008 | ||||||||
| LastUpdateDate: | 02/04/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/04/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | RN219439 | OH | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | APRN.CRNA.10348 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | P00689517 | 01 | OH | TRAVELERS RR MEDICARE | OTHER | 2940438 | 05 | OH | MEDICAID | PENDING | 05 | OH | MEDICAID |