Basic Information
| Provider Information | |||||||||
| NPI: | 1942676697 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MATHIS | ||||||||
| FirstName: | TRACY | ||||||||
| MiddleName: | STEVENS | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9510 ORMSBY STATION RD STE 100 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402234082 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5023279100 | ||||||||
| FaxNumber: | 8556328329 | ||||||||
| Practice Location | |||||||||
| Address1: | 9510 ORMSBY STATION RD STE 100 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402234082 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5023279100 | ||||||||
| FaxNumber: | 8556328329 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2015 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/23/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 3009474 | KY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | 3009474 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 13609091 | 01 | CAQH | OTHER | 7100380940 (KOHMG) | 05 | KY | MEDICAID | 201333300 A (KOHMG) | 05 | IN | MEDICAID |