1629040894 NPI number — TRACY LYNNE RUSSELL MD

Table of content: TRACY LYNNE RUSSELL MD (NPI 1629040894)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629040894 NPI number — TRACY LYNNE RUSSELL MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RUSSELL
Provider First Name:
TRACY
Provider Middle Name:
LYNNE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KNIGHTS
Provider Other First Name:
TRACY
Provider Other Middle Name:
LYNN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D,
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1629040894
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/19/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
611 N F ST
Provider Second Line Business Mailing Address:
STE 201
Provider Business Mailing Address City Name:
ABERDEEN
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98520-2667
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-533-7677
Provider Business Mailing Address Fax Number:
360-533-0470

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
611 N F ST
Provider Second Line Business Practice Location Address:
STE 201
Provider Business Practice Location Address City Name:
ABERDEEN
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98520-2667
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-533-7677
Provider Business Practice Location Address Fax Number:
360-533-0470
Provider Enumeration Date:
02/02/2006

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: 208000000X , with the licence number:  MD00046873 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1123256 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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