Provider Demographics
NPI:1104020064
Name:GUADAMUZ, TRACY CAROLINE (PT)
Entity Type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:CAROLINE
Last Name:GUADAMUZ
Suffix:
Gender:F
Credentials:PT
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 1321
Mailing Address - Street 2:
Mailing Address - City:STATE UNIVERSITY
Mailing Address - State:AR
Mailing Address - Zip Code:72467-1321
Mailing Address - Country:US
Mailing Address - Phone:870-930-0209
Mailing Address - Fax:870-934-8277
Practice Address - Street 1:1205 MCLAIN ST
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:AR
Practice Address - Zip Code:72112-3533
Practice Address - Country:US
Practice Address - Phone:870-523-0191
Practice Address - Fax:870-523-0195
Is Sole Proprietor?:No
Enumeration Date:2007-06-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAR2329225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR1306919071Medicare UPIN