Provider Demographics
NPI:1275725582
Name:MARTIN, TRACY OLIVER (NP)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:OLIVER
Last Name:MARTIN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:TRACY
Other - Middle Name:
Other - Last Name:OLIVER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP-C
Mailing Address - Street 1:PO BOX 911230
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75391-1230
Mailing Address - Country:US
Mailing Address - Phone:972-997-8000
Mailing Address - Fax:972-234-0813
Practice Address - Street 1:3410 WORTH ST STE 300
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75246-2012
Practice Address - Country:US
Practice Address - Phone:214-370-1500
Practice Address - Fax:214-370-1512
Is Sole Proprietor?:No
Enumeration Date:2007-08-10
Last Update Date:2017-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX696910363LA2200X
TXAP119253363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX220811802Medicaid
CO73237264Medicaid
COCO300679Medicare PIN
TX220811802Medicaid
CO73237264Medicaid