Provider Demographics
NPI:1225242415
Name:LIS, TRACY LYNNE (NP)
Entity Type:Individual
Prefix:MS
First Name:TRACY
Middle Name:LYNNE
Last Name:LIS
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 1:100 HIGH ST
Mailing Address - Street 2:C-368
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14203-1126
Mailing Address - Country:US
Mailing Address - Phone:716-859-2242
Mailing Address - Fax:716-859-2885
Practice Address - Street 1:100 HIGH ST
Practice Address - Street 2:C-368
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14203-1126
Practice Address - Country:US
Practice Address - Phone:716-859-2242
Practice Address - Fax:716-859-2885
Is Sole Proprietor?:No
Enumeration Date:2007-05-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY301389363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care