1962603530 NPI number — DR. TRACY ANNE TAGGART M.D.

Table of content: DR. TRACY ANNE TAGGART M.D. (NPI 1962603530)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962603530 NPI number — DR. TRACY ANNE TAGGART M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TAGGART
Provider First Name:
TRACY
Provider Middle Name:
ANNE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WIESBERG
Provider Other First Name:
TRACY
Provider Other Middle Name:
TAGGART
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1962603530
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/22/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1115 SE 164TH AVE DEPT 358
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VANCOUVER
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98683-8004
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-729-1462
Provider Business Mailing Address Fax Number:
360-729-3104

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
PEACEHEALTH UNITED GENERAL MEDICAL CENTER
Provider Second Line Business Practice Location Address:
2000 HOSPITAL DRIVE
Provider Business Practice Location Address City Name:
SEDRO WOOLLEY
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98284
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-856-7588
Provider Business Practice Location Address Fax Number:
360-856-7252
Provider Enumeration Date:
05/30/2007

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: 208600000X , with the licence number:  MD-48236 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208600000X , with the licence number: MD60957762 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2086S0127X , with the licence number: MD-48236 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208600000X , with the licence number: 27912 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 106538400 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".