Provider Demographics
NPI:1073760955
Name:TRACY, TRACEY KATHLEEN (MD)
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:KATHLEEN
Last Name:TRACY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:TRACEY
Other - Middle Name:KATHLEEN
Other - Last Name:HANRAHAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:506 4TH ST
Mailing Address - Street 2:
Mailing Address - City:LA GRANDE
Mailing Address - State:OR
Mailing Address - Zip Code:97850-1906
Mailing Address - Country:US
Mailing Address - Phone:541-663-3138
Mailing Address - Fax:541-975-5120
Practice Address - Street 1:506 4TH ST
Practice Address - Street 2:
Practice Address - City:LA GRANDE
Practice Address - State:OR
Practice Address - Zip Code:97850
Practice Address - Country:US
Practice Address - Phone:541-663-3138
Practice Address - Fax:541-975-5120
Is Sole Proprietor?:No
Enumeration Date:2008-08-22
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD151037207Q00000X
WAMD60747878207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500620109Medicaid
ORP00965892OtherRR MEDICARE
ORR154740Medicare PIN
OR500620109Medicaid