Provider Demographics
NPI:1285637207
Name:LARSON, TRACY M (MD)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:M
Last Name:LARSON
Suffix:
Gender:F
Credentials:MD
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 12734
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28220-2734
Mailing Address - Country:US
Mailing Address - Phone:704-390-7150
Mailing Address - Fax:
Practice Address - Street 1:6401 MORRISON BLVD # 2A
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-3800
Practice Address - Country:US
Practice Address - Phone:704-390-7150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-05-23
Last Update Date:2017-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9900925207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNC2421Medicaid
NC1285637207Medicaid
NC1285637207Medicaid
NCNCE78CAMedicare UPIN