1124196878 NPI number — MS. TRACIE L ATES CRNA

Table of content: MS. TRACIE L ATES CRNA (NPI 1124196878)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124196878 NPI number — MS. TRACIE L ATES CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ATES
Provider First Name:
TRACIE
Provider Middle Name:
L
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
CRNA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WALKER
Provider Other First Name:
TRACIE
Provider Other Middle Name:
L
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
CRNA
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1124196878
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/09/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4901 GRANDE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PENSACOLA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32504-5935
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-477-7042
Provider Business Mailing Address Fax Number:
850-474-9060

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4901 GRANDE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PENSACOLA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32504-5935
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-477-7042
Provider Business Practice Location Address Fax Number:
850-474-9060
Provider Enumeration Date:
12/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 367500000X , with the licence number:  ARNP9188008 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 590-63836 . This is a "BCBS" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: G3066 . This is a "BCBS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 009994370 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 304516100 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 115782800 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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