Provider Demographics
NPI:1083842520
Name:ROSS, TRACY L (APN)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:L
Last Name:ROSS
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1387 W 4TH ST
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-9766
Mailing Address - Country:US
Mailing Address - Phone:918-453-5554
Mailing Address - Fax:918-431-4112
Practice Address - Street 1:1387 W 4TH ST
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-9766
Practice Address - Country:US
Practice Address - Phone:918-453-5554
Practice Address - Fax:918-431-4112
Is Sole Proprietor?:No
Enumeration Date:2009-06-23
Last Update Date:2010-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA01450ANP363L00000X
OK09035013363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology