Provider Demographics
NPI:1093816274
Name:HANCOCK, TRACY (NP)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:HANCOCK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 62022
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77205
Mailing Address - Country:US
Mailing Address - Phone:616-734-0335
Mailing Address - Fax:616-949-8540
Practice Address - Street 1:4401 GARTH RD
Practice Address - Street 2:
Practice Address - City:BAYTOWN
Practice Address - State:TX
Practice Address - Zip Code:77521
Practice Address - Country:US
Practice Address - Phone:281-420-8600
Practice Address - Fax:281-837-8282
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2008-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX651121363LA2100X
CO175804363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO88379779Medicaid
8N7769OtherBCBS
CO88379779Medicaid