Provider Demographics
NPI:1083616627
Name:TRACY, JOEL M (CRNA)
Entity Type:Individual
Prefix:
First Name:JOEL
Middle Name:M
Last Name:TRACY
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:512 OAK CREEK DR S
Mailing Address - Street 2:
Mailing Address - City:VADNAIS HEIGHTS
Mailing Address - State:MN
Mailing Address - Zip Code:55127-7031
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8990 SPRINGBROOK DR NW
Practice Address - Street 2:STE 250
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-5850
Practice Address - Country:US
Practice Address - Phone:763-398-0099
Practice Address - Fax:763-398-0124
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR 087703-9367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN464264300Medicaid
MN430001652Medicare ID - Type UnspecifiedMC