1992024400 NPI number — MRS. TRACEY E KOLUND PA-C

Table of content: MRS. TRACEY E KOLUND PA-C (NPI 1992024400)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992024400 NPI number — MRS. TRACEY E KOLUND PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KOLUND
Provider First Name:
TRACEY
Provider Middle Name:
E
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HYDA
Provider Other First Name:
TRACEY
Provider Other Middle Name:
E
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1992024400
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/13/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 10190
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VIRGINIA BEACH
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23450-0190
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-477-5240
Provider Business Mailing Address Fax Number:
757-463-6572

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8303 DODGE ST
Provider Second Line Business Practice Location Address:
SUITE 300
Provider Business Practice Location Address City Name:
OMAHA
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68114-4108
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
403-354-5250
Provider Business Practice Location Address Fax Number:
402-354-3437
Provider Enumeration Date:
05/24/2010

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: 363A00000X , with the licence number:  002099 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 10025044500 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".




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